diabetic foot - managing and preventing ulcers

8/10/2019 Diabetic Foot - Managing and Preventing Ulcers

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Managing and Preventing Diabetic Foot Ulcers

Emerg Med 36(8):14-3! ""4

#$e a%t$ors e&'lain in detail $o to identi*! +%anti*! and address t$e actors t$at

determine %lcer $ealing rate! 'otential 'rogression to loer e&tremit* am'%tation! andli,eli$ood o rec%rrence in a given 'atient

.* #$omas Miller! MD! /cott 0 lar,! DPM! and .arr* /t%lts! MDDr Miller is assistant 'roessor o clinical medicine and Dr /t%lts is a 'roessor o clinical medicine int$e de'artment o medicine at t$e Universit* o Uta$ Medical enter in /alt 2a,e it* Dr lar, is avol%nteer associate 'roessor o s%rger* in t$e de'artment o s%rger* at t$e same instit%tion

0 64-*ear-old man it$ a 1-*ear $istor* o t*'e diabetes 'resented to a clinic it$ a

let $eel %lcer t$at $ad develo'ed several ee,s earlier! ater $e began earing a ne

'air o s$oes e also re'orted a t$ree-mont$ $istor* o cla%dication in $is let cal ater

al,ing a''ro&imatel* *ards is ot$er medical 'roblems incl%ded $*'ertension!d*sli'idemia! coronar* arter* disease! and de'ression

#$e %lcer (see '$oto) 'roved to be 'o'%lated it$ maggots! $ic$ ma* $ave minimi5ed

'%r%lent drainage rom t$e lesion #$e 'atient as admitted to t$e $os'ital

%naa* inection #$is %lcer began it$

a ne 'air o s$oes and ended in

am'%tation

#$e %lcer as e&'lored it$ a sterile 'robe t$at easil* reac$ed bone and also revealed

an e&tensive s%bc%taneo%s abscess Magnetic resonance imaging (M7) o t$e let $eel

demonstrated osteom*elitis o t$e calcane%s Pedal '%lses ere not 'al'able in t$e let

oot! and a s%bse+%ent an,le-brac$ial inde& (0.7) on t$e oot meas%red b* Do''ler

%ltraso%nd as "3 (normal! "9)

7nter'retation o t$e 0n,le-.rac$ial Press%re 7nde& 0.7 7nter'retation

"4 severe obstr%ction

"4 - "69 moderate obstr%ction;

"< - "9 mild obstr%ction;

"91 - 13 normal;

=13 medial arter* calciication;; >al%es ma* be alsel* $ig$ d%e to medial calciication it$ more severe

obstr%ction 'resent t$an indicated b* t$e 0.7

0ngiogra'$* o t$e let loer e&tremit* conirmed severe inra'o'liteal obstr%ction at

m%lti'le levels? vasc%lar s%rger* and radiologic cons%ltants elt t$at s%rgical and'erc%taneo%s revasc%lari5ation ere not easible #$e 'atient as managed it$


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re'eated s%rgical drainage and broad-s'ectr%m 'arenteral antibiotics oever! local

inection in t$e oot contin%ed to 'rogress! and a belo-t$e-,nee am'%tation as

necessar*

2@AE EB#EM7#C 0MPU#0#7@ 0D F@@# U2E

#$e above case scenario contin%es to be all too common 2oer e&tremit* am'%tations

(2E0s) in 'ersons it$ diabetes no e&ceed 1""!""" 'er *ear in t$e United /tates

#$e* increased in incidence b* 6 beteen 199" and """? "! 1"! and 4" o

t$ese am'%tations involve t$e leg! oot! or toe(s)! res'ectivel* Males and et$nic

minoritieses'eciall* ative 0mericans and! to a lesser degree! 0rican 0mericans and

is'anic 0mericansare at greatest ris, 0bo%t " o 'atients ill need a second

2E0 it$in ive *ears

Foot %lcers are t$e 'ro&imate ca%se o abo%t 8 o diabetic 2E0s Diabetic 'atients

$ave a ann%al incidence! 'revalence! and 1 lietime ris, o oot %lceration

#$e t$ree-*ear rec%rrence rate o diabetic oot %lcers! once $ealed! is nearl*


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Distal a%tonomic ne%ro'at$* can also lead directl* to 'lantar %lcers b* red%cing

seating in t$e eet! it$ s%bse+%ent dr*ing and iss%ring o t$e s,in /econdar*

bacterial inection and %lceration ma* ollo Peri'$eral arterial isc$emia occasionall*

'rod%ces isc$emic %lcers! b%t t$ese are less common (1 to incidence) t$an

ne%ro'at$ic %lcers (6) or combined ne%roisc$emic %lcers ()

Minor oot tra%ma! oten not recogni5ed b* t$e 'atient beca%se o sensor* ne%ro'at$*!

is t$e most common ac%te 'reci'itant o diabetic oot %lcers Mec$anical tra%ma

'redominates! es'eciall* rom ill-itting s$oes and less oten rom oreign bodies or

sel-tra%ma ind%ced b* c%tting nails or call%ses #$ermal tra%ma (rom $ot ater or a

$ot 'avement or sand! or e&am'le) and c$emical tra%ma (rom corn 'lasters! or

e&am'le) ma* also 'reci'itate %lcers in eet t$at are insensate beca%se o ne%ro'at$*

0bo%t 6 to 1" o diabetic oot %lcers develo' beteen t$e toes d%e to maceration

rom e&cessive moist%re and %ngal inection

Ait$o%t 'rom't and eective treatment! diabetic oot %lcers oten develo' a secondar*

bacterial inection /%'ericial inections o t$e o%nd ma* 'rogress to cell%litis!abscess and sin%s tract ormation! asciitis! or osteom*elitis /evere sot-tiss%e inection

o t$e distal oreoot can abr%'tl* 'reci'itate in sit% t$rombosis o digital end-arteries

and arterioles it$ s%bse+%ent gangrene o t$e toes 7n t$e 'resence o 'eri'$eral

arterial ins%icienc*! inection ma* be diic%lt to control! and %lcers ma* not $eal

%nless revasc%lari5ation can be accom'lis$ed

EB#E# 0D DEP# @F #E U2E

0''ro'riate assessment o diabetic oot %lcers s$o%ld identi* and +%anti* t$ose actors

t$at determine %lcer $ealing rate! 'otential 'rogression to 2E0! and li,eli$ood o

rec%rrence #$ese actors are t$e e&tent and de't$ o t$e %lcer! t$e 'resence and severit*

o inection! t$e 'resence and severit* o vasc%lar ins%icienc*! and 'at$ogenetic

actors and 'atient sel-care be$aviors t$at ma* $ave contrib%ted to %lcer ormation and

t$at ma* acilitate %lcer rec%rrence Dee'er! more e&tensive %lcers associated it$

conc%rrent inection or vasc%lar isc$emia! or es'eciall* it$ bot$! are at greatest ris, or

ail%re to $eal and 'rogression to 2E0

om're$ensive assessment s$o%ld be accom'lis$ed %rgentl* in t$e amb%lator* or

$os'ital setting and re+%ires a m%ltidisci'linar* team a''roac$! it$ 'ossible in'%t

rom 'odiatr*! inectio%s disease s'ecialists! vasc%lar s%rger*! and ort$o'edic s%rger*

Unort%natel*! a''ro'riate m%ltidisci'linar* assessment is oten dela*ed b* t$e 'atientor 'rimar* care clinician! or bot$! and t$is ma* res%lt in deterioration o t$e %lcer

o%nd! increasing t$e li,eli$ood o 2E0

#$e irst ,e* actor to assess is t$e e&tent and de't$ o t$e %lcer Diabetic oot %lcers are

re+%entl* more e&tensive t$an t$e* a''ear to be on s%'ericial e&amination Ulcer

de't$ is an im'ortant 'redictor o $ealing rate! li,eli$ood o conc%rrent osteom*elitis!

and ris, or am'%tation 0n e&'erienced clinician s$o%ld care%ll* e&'lore t$e o%nd

it$ a sterile bl%nt 'robe to determine i it 'enetrates to t$e tendon or Hoint ca's%le or

even to bone or into t$e Hoint s'ace! and $et$er s%bc%taneo%s abscess or sin%s tract

ormation is 'resent #$e li,eli$ood o osteom*elitis is 9" or $ig$er i t$e 'robe

contacts bone


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#$e baseline lengt$ and idt$ o t$e %lcer s$o%ld be meas%red Fail%re o t$e %lcer area

to decrease " or more ater one mont$ o a''ro'riate treatment is a strong 'redictor

t$at t$e %lcer is %nli,el* to $eal ater t$ree mont$s #$is ma* $el' to identi* 'atients

$o re+%ire more aggressive t$era'*

PE/EE 0D /E>E7#C @F 7FE#7@

7nection is an im'ortant determinant o t$e need or $os'itali5ation as ell as %lcer

$ealing rate and 'rogression to 2E0 0bo%t " or more o 'atients it$ severe

diabetic oot inections $ave no signs o s*stemic to&icit* s%c$ as ever! tac$*cardia! or

an increased or let-s$ited $ite blood cell co%nt om're$ensive assessment it$ a

'$*sical e&amination! laborator* testing! and radiogra'$ic st%dies is t$ereore necessar*

to classi* inection as absent! mild! or severe #$is classiication s*stem g%ides t$e %se

and selection o initial antibiotics and t$e decision as to $et$er to $os'itali5e 'atients

.acterial c%lt%res rom t$e o%nd! bone! or blood! or rom all t$ree! de'ending on t$e

clinical setting! ma* acilitate t$e decision to adH%st initial antibiotic t$era'*

P$*sical e&amination or signs o inection oc%ses on t$e 'resence or absence o ever!

tac$*cardia! or $*'otension and on t$e a''earance o t$e o%nd and adHacent tiss%es

7nection o t$e o%nd is demonstrated b* t$e 'resence o '%r%lent drainage or to or

more signs o inlammation (s%c$ as tenderness! armt$! ind%ration! or er*t$ema)

aro%nd t$e %lcer 7nection s$o%ld be considered severe i an* o t$e olloing

conditions are 'resent: abnormal vital signs? a rim o er*t$ema aro%nd t$e %lcer t$at is

cm or more in diameter? l*m'$angitic strea,ing or signs o asciitis (s%c$ as cre'itance

or b%llae)? or i t$e o%nd 'robe reac$es tendon! Hoint ca's%le! or bone or reveals a

sin%s tract or abscess

2aborator* testing or evidence o inection s$o%ld incl%de a $ite blood cell co%nt and

dierential! er*t$roc*te sedimentation rate (E/)! and gl%cose! bicarbonate! and

creatinine levels 2e%,oc*tosis or a s$it to t$e let (or bot$)! elevated E/ (above 4"

mmJ$r)! severe $*'ergl*cemia (gl%cose level o 3"" mgJdl or $ig$er)! metabolic

acidosis! or a5otemia rom de$*dration strongl* s%ggest t$e 'resence o severe

inection 0n E/ above 4" mmJ$r increases t$e li,eli$ood o conc%rrent osteom*elitis

1-old! $ile an E/ above


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it$ elevation o t$e oot or 1" min%tes! and s*stemic maniestations o inlammation

are not 'resent

7n t$e absence o an* o t$e above signs o inection! c%lt%res o t$e %lcer are not

indicated oever! $en s%c$ signs are 'resent! c%lt%res ma* $el' g%ide antibiotic

t$era'* i t$ere is an inade+%ate res'onse to t$e initial em'iric antibiotics /%'ericialcotton sab c%lt%res are inade+%ate #$e %lcer m%st irst be t$oro%g$l* debrided and

t$en cleansed it$ nonbacteriostatic saline! olloed b* tiss%e c%rettage or scra'ing o

t$e base o t$e %lcer #$e s'ecimen s$o%ld be s%bmitted or bot$ aerobic and anaerobic

c%lt%res

.lood c%lt%res are indicated in 'atients it$ a''arent s*stemic to&icit* .one bio's*

t$ro%g$ %ninected tiss%e ma* be necessar* to conirm t$e diagnosis and microbiolog*

o s%s'ected osteom*elitis

PE/EE 0D /E>E7#C @F >0/U20 7/UFF77EC

/evere 'eri'$eral arterial ins%icienc* ma* dela* or 'revent %lcer $ealing 7t ma* also

interact it$ severe distal oreoot inection to ca%se abr%'t digital arter* t$rombosis

and gangrene o t$e toes Persons it$ diabetes re+%entl* $ave inra'o'liteal

at$erosclerotic obstr%ction it$ relative s'aring o t$e more 'ro&imal arteries and t$e

arteries o t$e oot Prom't vasc%lar assessment is t$ereore essential in all 'atients!

olloed b* earl* revasc%lari5ation i critical isc$emia is 'resent

#$e 'atientGs 0.7 s$o%ld be determined b* Do''ler %ltrasonogra'$* in t$e 'resence o

an* o t$e olloing clinical indings: absence o bot$ t$e dorsalis 'edis and 'osterior

tibial '%lses? cla%dication s*m'toms in t$e cal! t$ig$! or b%ttoc, ater al,ing one

bloc, or less or oot 'ain s%ggestive o isc$emic rest 'ain? and a $istor* o 'eri'$eral

arterial disease 7nter'retation o t$e 0.7 is s%mmari5ed in t$e table

0 vasc%lar s%rgeon s$o%ld be cons%lted i t$e 0.7 is belo "4! or i t$ere is concern

abo%t a alsel* normal or elevated 0.7 d%e to medial calciication o t$e inra'o'liteal

arteries Meas%rements o toe s*stolic blood 'ress%re! transc%taneo%s o&*gen sat%ration!

'%lse vol%me recording! or %rt$er arterial imaging it$ d%'le& %ltraso%nd or M7 or

conventional angiogra'$* ma* be necessar* to determine t$e 'resence and severit* o

isc$emia

P0#@KEE#7 F0#@/ 0D /E2F-0E .E0>7@/

linicians m%st identi* t$e ,e* 'at$o'$*siologic 'at$a*s contrib%ting to %lcer

ormation in individ%al 'atients! so t$at t$ese actors can be eliminated or modiied! i

'ossible! to red%ce t$e li,eli$ood o %lcer rec%rrence Peri'$eral somatic sensor*

ne%ro'at$* contrib%tes to 9" or more o diabetic oot %lcers 7t is o'timall* detected in

t$e clinical setting %sing t$e "


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Patients it$ diabetes com'licated b* sensor* ne%ro'at$*! oot deormities! or isc$emia

m%st consistentl* 'ractice m%lti'le sel-care activities to 'rotect t$eir eet linicians

need to identi* $ic$ o t$ese activities t$e 'atient is not 'erorming reg%larl* #$e*

m%st also determine i t$ere are barriers t$at in$ibit t$ese activities De'ression! $ic$

is 'resent in 1 to o diabetic 'atients and oten %nrecogni5ed! and alco$olism!

or e&am'le! ma* serio%sl* red%ce motivation /ocial isolation combined it$ t$e'atientGs inabilit* to reac$ or see $is or $er eet ma* 'revent dail* oot ins'ection 0lso!

inancial constraints ma* ma,e it diic%lt or 'atients to '%rc$ase needed t$era'e%tic

ootear

P0#7E# M00KEME#

#$e critical irst ste' in t$e management o 'atients it$ diabetic oot %lcers is

cons%ltation it$ one or more s'ecialists rom 'odiatr*! ort$o'edic s%rger*! vasc%lar

s%rger*! t$e inectio%s diseases service! and t$e diabetic ed%cation service #$is

m%ltidisci'linar* a''roac$ $as been demonstrated in clinical trials to red%ce t$e

li,eli$ood o maHor am'%tation

0n* inection m%st be 'ro'erl* treated? 'atients it$ severe isc$emia m%st be

revasc%lari5ed! i 'ossible #$e o%nd m%st be immediatel* relieved o all 'ress%re to

'revent %rt$er damage! and eective local o%nd care m%st be administered Finall*! a

com're$ensive 'rogram to 'revent rec%rrence o diabetic oot %lcer and 2E0 is

essential

Patients s$o%ld be $os'itali5ed i t$eir inection is classiied as severe b* t$e clinical!

laborator*! or radiogra'$ic criteria disc%ssed earlier Patients it$ clinical evidence o

'eri'$eral arterial ins%icienc*! t$ose $o are %nli,el* to ta,e 'rescribed antibiotics or

to relieve 'ress%re on t$e %lcer! and t$ose $o are not available or 'rom't oice

ollo-%' it$in 4 to


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t$e broad s'ectr%m o isolates! oc%sing treatment on gram-'ositive aerobes it$ t$e

oral antibiotics listed in t$e table or a co%rse o one to to ee,s a''ears eective or

most mild inections

0ntibiotic Management o Diabetic Foot 7nection

Us%al organisms

o inection one

Mild inection /ta'$*lococc%s a%re%s

stre'tococci

enterococci

/ e'idermidis

gram-negative aerobes

/evere limb or 'ol*microbial:

lie-t$reatening / a%re%sinection gro%' 0 beta-$emol*tic stre'tococci

enterococci

gram-negative aerobes

anaerobes

0ntibiotic regimens

o inection one

Mild inection irst-generation ce'$alos'orin

diclo&acillin

amo&icillin-clav%lanate

clindam*cin

olo&acin alone or it$ clindam*cin

/evere limb- or beta-lactam-beta-lactamase in$ibitor

lie-t$reatening clindam*cin L +%inolone

inection clindam*cin L ceta5idime

imi'enem L vancom*cin

i lie-t$reatening inection

/evere limb- or lie-t$reatening inections are more li,el* to involve gram-negative

aerobic and anaerobic bacteria in addition to gram-'ositive aerobes Met$icillin-

resistant / a%re%s (M/0) organisms $ave been recovered it$ increasing re+%enc*

rom diabetic oot %lcers 0ccordingl*! one o t$e 'arenteral antibiotic regimens listed int$e table s$o%ld be %tili5ed initiall* or severe inections? 'atients it$ lie-t$reatening

inections s$o%ld be treated initiall* it$ a combination o imi'enemJ cilastin and! to

cover M/0! vancom*cin 0ntibiotic t$era'* ma* be re+%ired or to or more ee,s

For osteom*elitis! antibiotic t$era'* s$o%ld be based on bone bio's* microbiolog* and

administered or si& ee,s or longer /$orter co%rses o antibiotic treatment ma* be

'ossible i all inected bone is s%rgicall* removed /ome 'atients it$ diabetic oot

osteom*elitis ma* be eectivel* treated it$ 'rolonged antibiotic t$era'* it$o%t bone

resection

7 it is anatomicall* easible! 'atients it$ diabetic oot %lcers and severe isc$emias$o%ld %ndergo revasc%lari5ation it$ angio'last* or vasc%lar b*'ass 'roced%res Even


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it$ inra'o'liteal obstr%ction! s%ccess%l revasc%lari5ation ma* be accom'lis$ed in

man* 'atients 7 revasc%lari5ation is not 'ossible or in cases o severe 'rogressive

inection or e&tensive necrosis! am'%tation at some level ma* be re+%ired

E27E>7K PE//UE @ #E U2E

From t$e time o diagnosis %ntil t$e oot %lcer $as been $ealed or to or more ee,s!

%rt$er damaging 'ress%re and mec$anical stress on t$e %lcer m%st be eliminated or at

least minimi5ed at all times #$is ma* be accom'lis$ed or t$e irst e da*s it$

cr%tc$es or a $eelc$air /%bse+%entl*! 'atients can %se c%stom-made s$oes (s%c$ as

edged sandals or $al-s$oes)! ort$otic devices (s%c$ as removable cast al,ers)! or

total-contact casts to red%ce 'lantar 'ress%res on t$e %lcer $ile still alloing some

mobilit*

0ter t$e o%nd $as been debrided o all call%s and necrotic tiss%e! a arm! moist

environment s$o%ld be maintained t$ereater %sing saline dam'-to-dr* dressings or

ot$er dressings s%c$ as $*drogels! $*drocolloids! or alginates More absorbent dressingsma* be %sed i signiicant e&%date is 'resent #$ere is no evidence to s%''ort t$e %se o

to'ical en5*mes! and $*drot$era'* s$o%ld be avoided Peri'$eral edema s$o%ld be

eliminated or minimi5ed

For c$ronic diabetic oot %lcers o si& or more ee,sG d%ration! $ealing rates ma* be

im'roved b* a''l*ing to'ical grot$ actors (s%c$ as recombinant 'latelet-derived

grot$ actor) or bioengineered s,in or s,in s%bstit%tes 7nitial randomi5ed trials $ave

demonstrated a meas%rable beneit or t$ese e&'ensive t$era'ies! b%t t$e* s$o%ld

'robabl* be limited to 'atients $ose %lcers $ave not im'roved s%bstantiall* ater o%r

to si& ee,s o standard t$era'*

PE>E#7K EUEE 0D 0MPU#0#7@

ec%rrence rates it$ diabetic oot %lcers and 2E0 are as $ig$ as " to


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laces! b%c,les! or velcro! or at$letic or al,ing s$oes made rom leat$er or canvas and

o lig$ter colors #$e* s$o%ld ear 'rotective $o%se sli''ers in t$e $ome $en t$e* are

not earing s$oes Patients it$ more severe ne%ro'at$* and es'eciall* t$ose it$

severe oot deormities ma* re+%ire e&tra-de't$ and e&tra-idt$ t$era'e%tic s$oes! it$

c%s$ioned o-t$e-s$el or c%stom-made insoles Medicare 'a*s 8" o t$e 'a*ment

amo%nt alloed or one 'air o t$era'e%tic s$oes and to to t$ree 'airs o insoles 'er*ear i t$e a''ro'riate orms are com'leted b* t$e '$*sicians caring or t$e 'atient

Finall*! some 'atients it$ maHor oot deormities ma* beneit rom reconstr%ctive

s%rger* to 'revent rec%rrent oot %lceration /%rger* ma* be 'artic%larl* %se%l in

'atients $o are %nable to ear t$era'e%tic ootear

P0#7E# @U#@ME/

ates and s'eed o %lcer $ealing var* considerabl* among 'atients Patients it$

concomitant dee' inections or 'eri'$eral arterial isc$emia or $o re+%ire s%rger* $ave

loer $ealing rates and $eal more slol* @verall! " to 8" o 'atients it$ diabeticoot %lcers ill $eal it$in si& mont$s it$ o'timal management rom a

m%ltidisci'linar* team

/%ggested eading

0merican Diabetes 0ssociation: onsens%s Develo'ment onerence on Diabetic

Foot Ao%nd are:

diabetic foot - managing and preventing ulcers

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