Diabetic foot resident survival guide: Difference between revisions
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==Causes== | ==Causes== | ||
===Life Threatening Causes=== | ===Life Threatening Causes=== | ||
Life-threatening causes include conditions that may result in death or permanent [[disability]] within 24 hours if left untreated. [[Diabetic foot]] superseded with the following may result in [[sepsis]] and death. | Life-threatening causes include conditions that may result in death or permanent [[disability]] within 24 hours if left untreated. [[Diabetic foot]] superseded with the following may result in [[sepsis]] and death. | ||
*[[Infection (disambiguation)|Infected]] diabetic foot | *[[Infection (disambiguation)|Infected]] diabetic foot | ||
*[[Osteomyelitis]] | *[[Osteomyelitis]] | ||
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*[[Peripheral ischemia]] | *[[Peripheral ischemia]] | ||
* Improper footwear | * Improper footwear | ||
* Foot deformities including Charcot [[arthropathy]] <ref name="pmid20535310">{{cite journal| author=Pendsey SP| title=Understanding diabetic foot. | journal=Int J Diabetes Dev Ctries | year= 2010 | volume= 30 | issue= 2 | pages= 75-9 | pmid=20535310 | doi=10.4103/0973-3930.62596 | pmc=2878694 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20535310 }} </ref> | * Foot deformities including Charcot [[arthropathy]] <ref name="pmid20535310">{{cite journal| author=Pendsey SP| title=Understanding diabetic foot. | journal=Int J Diabetes Dev Ctries | year= 2010 | volume= 30 | issue= 2 | pages= 75-9 | pmid=20535310 | doi=10.4103/0973-3930.62596 | pmc=2878694 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20535310 }} </ref> | ||
==Diagnosis== | ==Diagnosis== | ||
Assessment of diabetic foot includes evaluation of peripheral arterial disease, peripheral neuropathy, and foot deformities. Shown below is an algorithm summarizing the diagnosis of diabetic foot and diabetic foot ulcers according to the recommendations of the American Diabetes Association | Assessment of diabetic foot includes evaluation of peripheral arterial disease, peripheral neuropathy, and foot deformities. Shown below is an algorithm summarizing the diagnosis of diabetic foot and diabetic foot ulcers according to the recommendations of the American Diabetes Association and International Diabetes Federation- Clinical Practice Recommendations on the Diabetic Foot 2017. {{cite web |url=https://www.idf.org/e-library/guidelines/119-idf-clinical-practice-recommendations-on-diabetic-foot-2017.html |title=Guidelines |format= |work= |accessdate=}} <ref name="pmid20535310">{{cite journal| author=Pendsey SP| title=Understanding diabetic foot. | journal=Int J Diabetes Dev Ctries | year= 2010 | volume= 30 | issue= 2 | pages= 75-9 | pmid=20535310 | doi=10.4103/0973-3930.62596 | pmc=2878694 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20535310 }} </ref> <ref name="pmid17276208">{{cite journal| author=Rathur HM, Boulton AJ| title=The diabetic foot. | journal=Clin Dermatol | year= 2007 | volume= 25 | issue= 1 | pages= 109-20 | pmid=17276208 | doi=10.1016/j.clindermatol.2006.09.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17276208 }} </ref> | ||
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==Treatment== | ==Treatment== | ||
Assessment of diabetic foot includes evaluation of peripheral arterial disease, peripheral neuropathy, and foot deformities. Shown below is an algorithm summarizing the diagnosis of diabetic foot and diabetic foot ulcers according to the recommendations of the American Diabetes Association <ref name="pmid27999003">{{cite journal| author=Pop-Busui R, Boulton AJ, Feldman EL, Bril V, Freeman R, Malik RA | display-authors=etal| title=Diabetic Neuropathy: A Position Statement by the American Diabetes Association. | journal=Diabetes Care | year= 2017 | volume= 40 | issue= 1 | pages= 136-154 | pmid=27999003 | doi=10.2337/dc16-2042 | pmc=6977405 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27999003 }} </ref> <ref name="pmid31862754">{{cite journal| author=American Diabetes Association| title=11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2020. | journal=Diabetes Care | year= 2020 | volume= 43 | issue= Suppl 1 | pages= S135-S151 | pmid=31862754 | doi=10.2337/dc20-S011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31862754 }} </ref> and International Diabetes Federation- Clinical Practice Recommendations on the Diabetic Foot 2017. {{cite web |url=https://www.idf.org/e-library/guidelines/119-idf-clinical-practice-recommendations-on-diabetic-foot-2017.html |title=Guidelines |format= |work= |accessdate=}} | Assessment of diabetic foot includes evaluation of peripheral arterial disease, peripheral neuropathy, and foot deformities. Shown below is an algorithm summarizing the diagnosis of diabetic foot and diabetic foot ulcers according to the recommendations of the American Diabetes Association <ref name="pmid27999003">{{cite journal| author=Pop-Busui R, Boulton AJ, Feldman EL, Bril V, Freeman R, Malik RA | display-authors=etal| title=Diabetic Neuropathy: A Position Statement by the American Diabetes Association. | journal=Diabetes Care | year= 2017 | volume= 40 | issue= 1 | pages= 136-154 | pmid=27999003 | doi=10.2337/dc16-2042 | pmc=6977405 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27999003 }} </ref> <ref name="pmid31862754">{{cite journal| author=American Diabetes Association| title=11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2020. | journal=Diabetes Care | year= 2020 | volume= 43 | issue= Suppl 1 | pages= S135-S151 | pmid=31862754 | doi=10.2337/dc20-S011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31862754 }} </ref> and International Diabetes Federation- Clinical Practice Recommendations on the Diabetic Foot 2017. {{cite web |url=https://www.idf.org/e-library/guidelines/119-idf-clinical-practice-recommendations-on-diabetic-foot-2017.html |title=Guidelines |format= |work= |accessdate=}} <ref name="pmid31862754">{{cite journal| author=American Diabetes Association| title=11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2020. | journal=Diabetes Care | year= 2020 | volume= 43 | issue= Suppl 1 | pages= S135-S151 | pmid=31862754 | doi=10.2337/dc20-S011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31862754 }} </ref> <ref name="pmid17276208">{{cite journal| author=Rathur HM, Boulton AJ| title=The diabetic foot. | journal=Clin Dermatol | year= 2007 | volume= 25 | issue= 1 | pages= 109-20 | pmid=17276208 | doi=10.1016/j.clindermatol.2006.09.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17276208 }} </ref> <ref name="pmid20535310">{{cite journal| author=Pendsey SP| title=Understanding diabetic foot. | journal=Int J Diabetes Dev Ctries | year= 2010 | volume= 30 | issue= 2 | pages= 75-9 | pmid=20535310 | doi=10.4103/0973-3930.62596 | pmc=2878694 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20535310 }} </ref> | ||
<SMALL>Adapted from ''Diabetes Care. 2013;36(9):2862-71.'' | <SMALL>Adapted from ''Diabetes Care. 2013;36(9):2862-71.'' and ''Clin Infect Dis. 2012;54(12):e132-73.''</SMALL> | ||
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==Do's== | ==Do's== | ||
* Check for signs of ischemia. | * Check for [[signs]] of [[ischemia]]. | ||
* Check for signs of infection. | * Check for [[Medical sign|signs]] of [[infection]]. | ||
* Always get a wound culture to determine the type of organism and choice of antibiotic. | * Always get a [[Culture media|wound culture]] to determine the type of [[organism]] and choice of [[antibiotic]]. | ||
* Prophylactic podiatric care. | *[[Prophylactic]] [[Podiatry|podiatric]] care. | ||
* Mechanical offloading in all patients. <ref name="pmid29979449">{{cite journal| author=Chang JW, Heo W, Choi MSS, Lee JH| title=The appropriate management algorithm for diabetic foot: A single-center retrospective study over 12 years. | journal=Medicine (Baltimore) | year= 2018 | volume= 97 | issue= 27 | pages= e11454 | pmid=29979449 | doi=10.1097/MD.0000000000011454 | pmc=6076129 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29979449 }} </ref> <ref name="pmid31862754">{{cite journal| author=American Diabetes Association| title=11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2020. | journal=Diabetes Care | year= 2020 | volume= 43 | issue= Suppl 1 | pages= S135-S151 | pmid=31862754 | doi=10.2337/dc20-S011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31862754 }} </ref> | * Mechanical offloading in all patients. <ref name="pmid29979449">{{cite journal| author=Chang JW, Heo W, Choi MSS, Lee JH| title=The appropriate management algorithm for diabetic foot: A single-center retrospective study over 12 years. | journal=Medicine (Baltimore) | year= 2018 | volume= 97 | issue= 27 | pages= e11454 | pmid=29979449 | doi=10.1097/MD.0000000000011454 | pmc=6076129 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29979449 }} </ref> <ref name="pmid31862754">{{cite journal| author=American Diabetes Association| title=11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2020. | journal=Diabetes Care | year= 2020 | volume= 43 | issue= Suppl 1 | pages= S135-S151 | pmid=31862754 | doi=10.2337/dc20-S011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31862754 }} </ref> | ||
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Revision as of 02:38, 11 August 2020
Resident Survival Guide |
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Introduction |
Team |
Guide |
Page Template |
Examine the Patient Template |
Navigation Bar Template |
Checklist |
Topics |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ifrah Fatima, M.B.B.S[2]
Overview
This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.
Causes
Life Threatening Causes
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. Diabetic foot superseded with the following may result in sepsis and death.
- Infected diabetic foot
- Osteomyelitis
Common Causes
- Poor glycemic control
- Peripheral neuropathy
- Peripheral arterial disease
- Peripheral ischemia
- Improper footwear
- Foot deformities including Charcot arthropathy [1]
Diagnosis
Assessment of diabetic foot includes evaluation of peripheral arterial disease, peripheral neuropathy, and foot deformities. Shown below is an algorithm summarizing the diagnosis of diabetic foot and diabetic foot ulcers according to the recommendations of the American Diabetes Association and International Diabetes Federation- Clinical Practice Recommendations on the Diabetic Foot 2017. "Guidelines". [1] [2]
Characterize the symptoms: ❑ Onset ❑ Type of sensation ❑ Location ❑ Nocturnal variation ❑ Aggravating factors ❑ Relieving factors Obtain a detailed history: ❑ Onset of diabetes ❑ Duration of diabetes ❑ Compliance with medication ❑ History of glycemic control ❑ History of other diabetic complcatios ❑ Foot deformities/injuries/ulcers ❑ History of lower limb amputation ❑ Type of footwear ❑ Foot hygiene ❑ History of claudication ❑ Smoking history | |||||||||||||
Examine the patient: Inspection ❑ Location of ulcer ❑ Integrity and charcteristic (dry/cracked) of skin ❑ Sweating Palpation ❑ Pedal (dorsalis pedis) pulses ❑ Vibration sensation ❑ Ulcer site- warmth, tenderness, edema Non-invasive tests ❑ Semmes-Weinstein monofilament test ❑ Probe-to-bone test if suspected osteomyelitis ❑ Measure ABI (Ankle-Brachial Index) with a Arterial doppler | |||||||||||||
Order tests: ❑ Glycosylated hemoglobin/ HbA1c ❑ Fasting plasma glucose ❑ Complete blood count ❑ ESR and CRP ❑ Deep tissue specimen for culture | |||||||||||||
Treatment
Assessment of diabetic foot includes evaluation of peripheral arterial disease, peripheral neuropathy, and foot deformities. Shown below is an algorithm summarizing the diagnosis of diabetic foot and diabetic foot ulcers according to the recommendations of the American Diabetes Association [3] [4] and International Diabetes Federation- Clinical Practice Recommendations on the Diabetic Foot 2017. "Guidelines". [4] [2] [1]
Adapted from Diabetes Care. 2013;36(9):2862-71. and Clin Infect Dis. 2012;54(12):e132-73.
Prophylactic measures and Diabetic foot care in all patients ❑ Glycemic control ❑ Apporpriate footwear and podiatric care • ❑ Mechanical offloading • Cast Walkers • Total contact casting • Therapeutic shoes ❑ Vascular care to prevent and treat peripheral arterial disease | |||||||||||||||||||||||||||||||||||||||||||
❑ Local wound care ❑ Debridement | |||||||||||||||||||||||||||||||||||||||||||
Peripheral arterial disease or signs of ischemia | Medication/Surgical or endovascular revascularization | ||||||||||||||||||||||||||||||||||||||||||
Presence of infection | • Mechanical or chemical wound debridement • Culture • Biopsy | ||||||||||||||||||||||||||||||||||||||||||
• Assess severity of infection according to the table below • Treat with antiobiotics according to the table below | |||||||||||||||||||||||||||||||||||||||||||
If infection does not resolve within 30 days- • Consider hyperbaric oxygen therapy | |||||||||||||||||||||||||||||||||||||||||||
• Observe foot • Establish regular care • Reassess in 2-3 months | |||||||||||||||||||||||||||||||||||||||||||
- DFI is classified based on its severity according to the Infectious Diseases Society of America (IDSA) guideline or the PEDIS grade developed by International Working Group on the Diabetic Foot (IWGDF). (see Table below)
- Selection of empiric antimicrobial regimen should be determined by the severity of DFI and the likely etiologic agents.
|
- 5. What is the appropriate route, setting, and duration of antibiotic therapy?
- The table below describes the recommended route, setting, and duration of antibiotic therapy based on the extent and severity of DFI.
|
Empiric Therapy
▸ Click on the following categories to expand treatment regimens.
Uninfected (Grade 1) ▸ No Evidence of Infection Mild (Grade 2) ▸ Acute Infection Without Recent Antibiotic Use ▸ High Risk for MRSA
Moderate to Severe (Grade 3–4) ▸ Chronic Infection or Recent Antibiotic Use ▸ High Risk for MRSA ▸ High Risk for Pseudomonas aureuginosa ▸ Polymicrobial Infection |
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Do's
- Check for signs of ischemia.
- Check for signs of infection.
- Always get a wound culture to determine the type of organism and choice of antibiotic.
- Prophylactic podiatric care.
- Mechanical offloading in all patients. [5] [4]
Don'ts
- The content in this section is in bullet points.
References
- ↑ 1.0 1.1 1.2 Pendsey SP (2010). "Understanding diabetic foot". Int J Diabetes Dev Ctries. 30 (2): 75–9. doi:10.4103/0973-3930.62596. PMC 2878694. PMID 20535310.
- ↑ 2.0 2.1 Rathur HM, Boulton AJ (2007). "The diabetic foot". Clin Dermatol. 25 (1): 109–20. doi:10.1016/j.clindermatol.2006.09.015. PMID 17276208.
- ↑ Pop-Busui R, Boulton AJ, Feldman EL, Bril V, Freeman R, Malik RA; et al. (2017). "Diabetic Neuropathy: A Position Statement by the American Diabetes Association". Diabetes Care. 40 (1): 136–154. doi:10.2337/dc16-2042. PMC 6977405 Check
|pmc=
value (help). PMID 27999003. - ↑ 4.0 4.1 4.2 American Diabetes Association (2020). "11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2020". Diabetes Care. 43 (Suppl 1): S135–S151. doi:10.2337/dc20-S011. PMID 31862754.
- ↑ Chang JW, Heo W, Choi MSS, Lee JH (2018). "The appropriate management algorithm for diabetic foot: A single-center retrospective study over 12 years". Medicine (Baltimore). 97 (27): e11454. doi:10.1097/MD.0000000000011454. PMC 6076129. PMID 29979449.