LUDWIG'S ANGINA

I was working in the emergency department for a quick six hour shift. The twelve hour shift was split between me and another nurse. I liked those every once in a while for extra money. I had the first half starting at 0700. I was assigned to four beds in the non-monitored section. This was a nice change since I usually ended up in the monitored section. The non-monitored section was considered “non-emergent” for the most part and the patients were usually discharged home.

The morning was starting out to get busy. My beds were full. Every time I discharged somebody there was somebody from triage to come back. This area was a faster pace compared to the monitored patients who we seem to sit on for hours. After discharging one of my patients I quickly walked to the nurse’s station to finish my paperwork. I watched the triage nurse wheeling a male patient towards my empty bed. I quickly finished the paperwork and went to the bedside. The triage nurse gave me the report of a 35-year-old male, Brad, with the complaint of neck swelling beginning yesterday and getting worse. Brad had dental work done yesterday morning for an abscessed tooth. He had a low grade fever of 100.7 orally which began yesterday afternoon. Brad had no difficultly with breathing and was speaking clearly without any problems. His BP was 129/84, pulse 89, respirations 18, and room air pulse oximetry 99%. His neck was red and warm to touch. The best analogy I could give for Brad’s appearance was a bull frog with a puffed out chin. He was asked to get into one of our gowns and sit on the bed. He was told the E.D. physician would be in shortly.

The E.D. physician did his assessment and wrote orders for a CT of the neck, IV, CBC, chemistries, and blood cultures. I quickly grabbed my IV and blood drawing equipment. The blood culture bottles were in another cabinet. When drawing blood cultures there was a protocol to follow in this hospital to prevent contaminated specimens. This included using betadine swabs and alcohol by preparing the site like performing a sterile procedure. The site for the IV needed to be free of all organisms. The final culture report would be read in 48 hours. If there were indications of contamination of the site caused by improper technique, the nurse or tech would get a letter from the manager in the lab. After several letters they required the staff member to re-demonstrate the correct procedure for drawing blood cultures. Needless to say, nobody liked to do them because they had received letters.

I gathered all of my equipment and went to Brad’s bedside. I explained everything the E.D. physician ordered and what would happen in what order. The IV and blood work needed to be drawn first before he went to CT. Brad agreed. The blood would be drawn from the IV catheter using a vacutainer. I started the IV and made sure I was a good nurse and followed the blood culture policy. Lord knows I didn’t want the blood culture police to find something wrong and get a no-no letter.

After delivering the blood work to the lab I wheeled Brad to CT. He remained stable without any changes since being admitted to the E.D. He also maintained a good sense of humor even though he was not feeling his best. He was in CT for approximately 20 minutes before being wheeled back to his room. Now it was a matter of waiting for all of the test results to come back. I checked on Brad frequently to make sure he was doing okay. I also had three other patients to care for. They were also in a waiting mode for test results or IV fluids to finish.

About one hour later all of Brad’s test results were back. It was determined Brad had Ludwig’s Angina. This was cellulitis of the sublingual and submaxillary spaces usually caused by a tooth infection. It can be life threatening because the swelling could compromise the airway. A request for an ICU bed was placed and IV antibiotics and oxygen via nasal cannula were ordered. I got the antibiotic running and got one of our portable cardiac monitors from the counter. I put on the nasal cannula at 3 liters. Brads condition remained unchanged.

The interesting thing about this case was Brad had already been in the E.D. for about three hours without being monitored. One of the policies of admitting a patient to the ICU was they had to be monitored and have oxygen. If a patient was brought to the unit without these, the ICU nurses would complain and the E.D. director would probably hear from the ICU director. So in order to play nice these things were put on before I brought Brad to the ICU.

Brad was in the ICU for two days. He was responding well to the IV antibiotics and the swelling in his neck and chin were decreasing. He never had any airway difficulties during his hospital stay. He was discharged home after being in the hospital for four days.