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Wave 2: Module 2: Lower Limb – Week 4 – Case 2
DIABETIC FOOT COMPLICATIONS
CASE 2
A 64 years old male presenting to A&E with fever and general unwellness. His wife describes that he has been having worsening Lt foot pain for the last 3 days and started to become smelly on the day before.
•PMHx
DM-II on insulin, HTN, IHD
•Physical Examination
Wet necrosis of the Leftt foot
Difficult to feel any pedal pulses in the foot because of tissue edema but good signals with hand held doppler over DPA can be heard
•Blood Tests
Hb 89 g/dl, WBC 18 x 109/L, CRP 220 mg/dl
•Questions:
1.Discuss the steps of your immediate management plan
2. Discuss your long term management plan.
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Step 1 immediate
step 2 long term
Immediatly I will order xray on the foot to check for oatromeyleitis or bone eroaion
Immediate hospitilzation on ICU (patient about to be in septic shock)
Croas match for 1 unit of blood to be done
Immediate empircal anitobotic given to conever both G+ nd G – and anaerobic bacteria
I will do incsion drainge to drain the collection then culture and sensitivty from that fluid
ThenI will oder duplex commenting on patency of the vessels from CFA to DPA
I will draw full lab after drainge if auitable S.cr is present I will do CTA to review the arteria tree characterstics and then according to the CTA the patient Either go angioplasty obypass
I think if DPA is heared well we can amputate the thrid toe
After that we will foucs on tigh glycemic control together with anti-ischemia measures
Ans antibiotic form the culture and follow up the wound for any defective healing
Thia to be assosiated with complete offloading ans follow up with podiatrist,endocrionlogist,nutritionist,
A1 hospitalization
hx taking…
examination especially temp, BP and HR monitoring
invs.. CBC, S crt , duplex: easy and fast method to exclude the presence of PAD , significant stenotic plaques
Pt needs adequate resuscitation, good antibiotic control, urgent drainage with adequate drainage of the respective foot compartment. further amputation if the toe if PAD is excluded by duplex US, tissue sample shall be sent for culture and sensitivity including bone biopsy
A2
pt needs tight glycimec control with smoking cessation, needs 4- 6 weeks of antibiotics adjusted to culture and sensitivity, control of modifiable risk factors as smoking. aspirin and statin. offloading is required of healing of the tissue lesion and adequate dressing
those targets are achieved by followup with multidisciplinary team of diabetitian, podiatrist, vascular surgeon.
A 1-
admission of patient
start sepsis 6 give patient o2 and antibiotics and fluids
withdraw full lab and lactate and blood culture -crp – lipid profile -HBA1c
measure ABI and duplex of ll and cta -xray foot
this patient needs urgent intervention either 2 -3 – 4 toe amp or TMTA
and offloading and dressing
A2 long term
control of risk factors
assess vascularity of the patient
and give aspirin – statin
foot offloading
surgical debridment if needed
daily dressing
Podiatrist follow up
Nutrionist follow up
Diabetologist follow up
modify antibiotics according to culture
Management
. Admission
Hydration
Antibiotics
Swab culture
Blood culture
Full lap
X ray
Diabetologist consulting
Anasthesia consultation
Toe amputation with culture and sensitivity
——————
Post op antibiotics
Daily dressing of wound
Life style modification
Off loading
Podiatrist follow up
Nutrionist follow up
Diabetologist follow up
Vascular follow up
immediate management
Good pedal flow by hand held dopplar
Admission
And resuscitation I fluids
Empirical ABs
Full lab (CBC, INR, CRP, S. creat., ALT, AST, HbA1C)
X-Ray foot (Post Ant and lateral views) for gases and osteomyelitis
Consent for toe amputation (3rd and 4th)
Urgent amputation and take biopsy to adjust Abs according to results
….
Long term management plan.
Diabetes control, lipid lowering
Neutitiomal support
agent, Aspirin
Foot Care, daily dressing
Culture guided antibiotics
VAC therapy according to wound state
regular follow up outpatient
Reassessment of vascular state after resolving of edema and acute infection stage
steps of immediate management plan:
Long term management plan.
Q(1):
This patient needs urgent hospital admission,
then to be prepared for IV fluids resuscitation and antipyretics.
Wound swab for culture and sensitivity tests.
Broad spectrum IV antibiotics, ECG.
Plain X-ray LT foot to exclude osteomyelitis.
Urgent amputation of toes up to LT TMA.
ABPI and arterial duplex US.
Control of DM and HTN.
Q(2):
Follow up of wound by daily dressing and consider VAC therapy or hyperbaric O2 if can be added.
Cardiology consultation for medications
Diabetologist for control of D.M
Podiatrist for wound care
Assess vascularity post-operative.
Best medical treatment (vasodilators, antiplatelets and statins).
Antibiotics according to the results of culture and sensitivity tests.
Nutritionist for diet suitable to the patient.
A1: immediate plan
Admission resuscitation prepare for urgent debridement and drainage with toes amputation with culture and sensitivity along with blood transfusion
Xray foot
ABPI then Duplex arterial for vascular evaluation and the need for revascularization
DM control antibiotics
A2: long term plan
Long term antibiotic in case of OM for 6 wks
Diabetic control endocrinologist
Htn control cardiologist
Statins with anti platelets and low dose rivaroxiban after revascularization
Nutrition
Podaitrist foot wound care dressing
Orthotist offloading
Neurologist for neuropathic foot
A1..
From examination and history and labs . There is sever diabetic foot infection with gangrene
At First patient must be admitted with starting IV fluids and broad spectrum antibiotics then I will do ECG and cardiac evaluation and aneathesia consultation for forefoot amputation .
I will send tissue culture from base of the wound
A2..
After resolving of edema I will re exam for checking peripheral pulsation .
Proper wound dressing with offloading of the wound
Proper antibiotic therapy according to culture and sensitivity.
If peripheral pulsation is still not felt I will arrange for imaging to exclude any proximal lesion
this patient considered in sepsis and needs to be admitted and resuscitated iv fluids and iv antibiotics and good glycemic control
x-ray foot and leg to assess the extent of the infection
urgent surgical debridement of the foot
assessment of the vascularity intraoperative and after the surgery to assess the progression of the wound given Good signals to the foot
assessment of the pulsation and ABI and duplex ultrasound if vascularity of the wound was affected and intervene accordingly
follow up of the wound and appropriate dressing to promote healing
follow up with endocrinologist to control of his blood sugar
follow up with podiatrist for appropriate offloading and foot wear
follow up with a nutritionist for appropriate nutrition to promote wound healing