•A 62 years old male presenting with painful non-healing ulcer on the right foot for 2 months. He noticed a small blister on the dorsal aspect of his right foot 2 months ago, which has since increased in size and developed foul-smelling discharge. He reports worsening pain over the past two weeks, especially at night, partially relieved when hanging his foot over the edge of the bed.
•PMHx
DM-II on insulin, HTN, history of MI 5 years ago, heavy smoker
•Physical Examination
Ulcer on the dorsal aspect of Rt foot, with slough and purulent discharge with surrounding erythema and mild swelling. There is blackened necrotic tissue
No palpable pedal pulses in the foot, only palpable femoral pulse.
•Blood Tests
Hb 82 g/dl, WBC 13 x 109/L, CRP 95 mg/dl
•Questions:
1.Discuss the steps of your immediate management plan
2.Discuss your long term management plan.
A1 i will manage the patient according to ccrisp protocol
maintain airway and breathing by o2 mask
insert 2 large bore cannula and start fluid resusitation
start iv broad antibiotics
measure lactate level and ABG and cbc -glucose level kidney function test -hbA1c
withdraw blood culture and wound swab
xray foot and ABI
monitor uop and patient vitals
immediate debridment for wound and dressing
A2 long term assessment
endocrine consultation and Bp and DM control
heel off loading
foot care and dressing
duplex asessment and ABI
CTA to asess vascular tree and plan for needed intervention either angioplasty or bypass according to level and length of occlusion
monitor patient inflammtory markers and wound
may need 2nd debridment
1-A-Foot X-ray ,Admission, intra operative depridement , arterial duplex
B-Resuscitation + I’ve antbiotics after wound and blood cultures
2- Arterial duplex +_ cat Vse angiography guided kidney function normal if not Co2 Angioplasty
immediate management includes duplex, ultrasonography arterial system of the lower limb
incision drainage for controlling infection
planning for urgent revascularization of the lower limb, which includes scrt, CTA
for angioplasty or bypass
tight glycemic control and adequate antibiotic coverage adjusted to culture and sensitivity
long term management includes lifestyle modification including smoking cessation and exercise therapy, antibiotic which ischemic TTT as aspocid , petal/ cilostazol and lipid lowering statistics , with post revascularization debridement and daily dressing
Immediate management steps
Mechanical debridement
Chemical debridement
Antiplt
Statin
Cilistazole
Bp control by ACE
——
S . Creat analysis
Hba1c
Lipid profile
Arrang ct angiography urgent
—————
Long term manage
Revascularization
Glycemic control
Wound care management
Off loading
Best medication
Follow up
Q1.short term management:
Admission to hospital, full laboratory investigations .
anti ischemic “Best medical ttt
Broad spectrum Antibiotics , cultures.
CTA , and plane revascularization before depridment or surgical intervention.
Q2. Long term management:
Control DN ,and other Risk factors, stop smoking.
Dressing and wound care
Q2: long term management:
and no need for offloading in this patient.
Q1: immediate management: now this patient has CLTI and infected ischemic ulcer.
my main goals is the surgical intervention e.g., debridement and revascularization either open or endovascular
Q1 regarding Immediate Management Plan:
>> initial assessment and management
Analgesia: Administer appropriate pain relief.
Control of infection: Start broad-spectrum antibiotics immediately to cover polymicrobial infections.
Fluid resuscitation: If there are signs of systemic sepsis or dehydration, initiate IV fluids.
Blood transfusion: as patient Hb is 82 g/dl indicates mostly chronuc disease anemia, revise his old CBCs.
>> Wound Management
Debridement: urgent surgical debridement crucial to reduce bacterial load and promote healing.
>> Vascular evaluation:
Doppler ultrasound/Ankle-Brachial Index (ABI): Assess arterial blood flow in the affected limb.
CTA/MRA according to patient kidney function,
>> Glycemic Control
Optimize blood glucose with endocrinologist consultation.
Q2 Long-term Management Plan:
>> Peripheral Arterial Disease (PAD)
Revascularization: Depending on the vascular assessment, this maybe angioplasty, stenting, or bypass surgery.
Antiplatelet therapy
Exercise therapy: Supervised programs to improve circulation (if revascularization is successful).
lifestyle modification: Include a low-glycemic index diet and weight optimization.
Smoking Cessation
>> Cardiovascular Risk Management
Optimize blood pressure control (e.g., ACE inhibitors/ARBs, beta-blockers).
Continue post-myocardial infarction therapy (e.g., beta-blockers, aspirin, statins).
Lifestyle changes to reduce cardiovascular risk.
>> Limb and Foot Care
Educate the patient on daily foot inspection to identify early signs of trauma or ulceration.
Provide appropriate foot off loading.
>> Follow-up
of his wound and arterial circulation.
urgent admission
management according to CCRISP protocol and SEPSIS 6 regimen
measure ABPI
liaising with endocrinology and anesthesia
lab and foot x-ray and CTA
urgent debridment
revascularization of the wound either open or endo
wound care- offloading
regular follow up for the foot
strict glycemic control
***** the photo under the question is not related to the question ****
1- the case is about ischeamia infected diabetic foot. first the patch of gangrene on the dorsum has established and infected line of seperation so i will start by debridement of this patch of gangrene, take tissue culture and start anti g+ve abs, anti ischeamic, pain control.
Then assessment of degree of ischeamia by ABI, arterial duplex, vein map, echo, correction of anemia and hypoalbumineamia if found
METS score of the patient and function of the limb and determine either conservative ttt, 1ry amputation or revascularization.
CTA and plan emergent revascularization if decided
2- long term about ulcer care, anti ischeamic drugs, stop smoking,blood glucose level control, avoid tight shoes and
*followup of vascular Reconstruction done either endovascular or surgery was done.
immediately i will admit the patient and order iv antibiotics and xray foot and leg
ABI of the right lower limb
urgent debridement to eradicate the source of sepsis and also to assess the salvegability of the limb and its functionality
the revascularization in the form of endovascular trial to give pulsatile flow to the foot
after successful revascularization ,wound care management in the form of dressing and offloading and glycemic control and patient education about his wound and warning signs of deterioration of the wound
1 after full history and examination and
ABI
Investigations as
laboratory CBC , INR , s.creat
X Ray
Arterial duplex
Prepare pt for Urgent debridement
Wound culture and give emperical antibiotics, anti ischemic medications
and other medications according to pt state
Revascularization according to ABI and Arterial duplex as soon as possible if needed (within 2 weeks)
2 wound care
Offloading
Good control of risk factors
q1 …….THIS PATIENT has rt CLTI and this is based on the fact that he has foot necrotic tissues alongside with rest pain in the foot that disappears only by hanging the foot over the bed edge also there is offensive discharge from the foot with mildly elevated WBCs and CRP
so this patient also has a foot infection
based on the above this patient needs hospital admission with the administration of IV empirical antibiotics and IV fluids
after admission, I will ask for a full lab and ECG with cardiac consultation
I will ask for an urgent x-ray of the foot and an urgent CT angiography then according to CTA result, i will plan for revascularization and proper debridement of necrotic tissues
if there will be a delay at CTA I will progress for drainage and debridement of necrotic tissues to prevent the progression of infection and gengreen
q2 …. my long-term plan after revascularization will be a continuation of systemic antibiotics for at least 4 weeks .. with daily dressing and proper wound care also offloading of the wound is very important
I will describe long-term single antiplatelet therapy and statin with surveillance follow up by arterial duplex US to follow up revascularization procedure that had been done to detect and prevent its future occlusion
Q:1 The patient is presented with RT L.L CLTI and DFI.
Immediate hospital admission….Fluid rescusitiation and IV antibiotics.
Full labs: CBC, coagulation profile, lipid profile and renal functions.
Wound swab for culture and sensitivity tests.
ABPI measurement, Plain Xray RT Foot to detect osteomyelitis.
Patient needs urgent revascularization and extensive debridment so prepare
her for CT angio to detect arterial tree lesions for endovascular vs open surgery.
Preoperative cardiology consultation and pre-operative fitness.
Q:2 I will discuss with patient about her long term management plan and tell her about the risks, what to expect and the prognosis.
Cessation of smoking and control of risk factors.
Diabetologist is needed to control Diabtes mellitus.
Post-operative follow up by ABPI measurement and medcations.
Wound care management and Podist for diabetic foot shoes.
1.Discuss the steps of your immediate management plan
PT diagnosed as cli and planned for revascularization
Abi assessment+ full lab assessment urea creat lipid profile pt pc
Wound care
CTA for assessment of inflow and out flow
Preoperative cardiac assessment and preoperative fitness
Prepare for intervention PTA Vs surgery +Wound management
2.Discuss your long term management plan.
PT education about his condition and what to expect and prognosis risk of amputation
Tight control of risk factors
Prepare PT for PTA Vs surgery
Post operative follow up of ABI and Wound management risk factors control