Management of Trophic Ulcer in a Diabetic

MANAGEMENT OF TROPHIC ULCER

IN A DIABETIC

IN PHC SETTING

DIABETES IS ESSENTIALLY A METABOLIC DISORDER CAUSED BY LITTLE OR NO ABILITY OF THE PANCREAS TO PRODUCE INSULIN WHICH LEADS TO CHRONIC HYPERGLYCEMIA AND BOTHACUTE- KETOACIDOSIS

HYPEROSMOLARITYCHRONIC- MACROANGIOPATHY

MICROANGIOPATHYNEUROPATHY

COMPLICATIONS

DIABETIC FOOT

PATHOGENESIS:

20%-NEUROPATHY70%-NEUROISCHAEMIC10%-ISCHAEMIC

TROPHIC ULCERULCERATION IN THE NEUROPATHIC FOOT DEVELOPS IN POINTS OF INCREASED MECHANICAL PRESSURE ON THE SOLE AND DISTAL END OF TOES

ISCHAEMIC LESIONS ARE USUALLY LOCATED ON FOOT SIDES AND TOES AND THEY ARE MORE SEVERE

CLINICAL CLASSIFICATION OF DIABETIC FOOT LESIONS

GR 0-AT RISK FOOTGR 1-SUPERFICIAL ULCERGR 2-DEEP ULCER,INFECTED,NO BONE INVOLVEMENTGR 3-DEEP ULCER, ABSCESS, BONE INVOLVEDGR 4-LOCALISED GANGRENEGR 5-GANGRENE OF WHOLE FOOT

Neuropathy, microangiopathy, infection

spreading ulcer

cellulitis

abscess

gangren

osteomyelitis

gangrene

Septicemia & ketoacidosis

Risk factors for diabetic foot

H/O ulceration – perforating plantar ulcerIntermittent claudicatingDeformity-callus, claw toes, flat footLoss of temp, discrimination, pain & vibration(at least 2)Evidence of haemodynamicallysignificant PVD on investigation

EvaluationCLINICAL:

SensoryMotorAutonomic

INVESTIGATIONS

CBPBlood and urine sugarPus for c/sX-ray footECG, chest x-rayOthers: LFT, urea, creat. ,electrolytes ,LL angio.

Prevention

Diabetics not at high risk:

Foot care, file nails, wear comfortable well fitting shoesStop smokingAim for max glycaemic controlRegular exercise

Diabetics at high risk:Inspect foot dailyReport any lesion or suspected change of colourNever walk bare footWash feet daily….Nail careFoot wear- MCRDo not expose feet to extremes of temperature

Management

Broad spectrum antibioticLocal debridement of necrotic areas / I&DFrequent dressings

Grade 2& above

Rest the limb, avoid wt bearingEnsure adequate drainageRinse with disinfectant and dry dressing( no ointment)

Grade 1

Strict metabolic control- reg. insulin Prompt RX of superficial fungal/ bacterial infectionsTT prophylaxis

Grade 0

Management contd..

Tertiary level:

Revascularisation procedures if significant ischaemia

Amputation if the above measures fail and gangrene develops

IN OUR RHCControl of diabetes:

sliding scaleControl of infection:

Culture and sensitivity, antibioticsmultiple abscesses :- I & D

Local treatment of diabetic foot:Healing :- cleaning & dressingNon- healing :- H2O2/ Ensol/ iodine solSpreading :- debridement

General management

Diabetic dietExerciseOral hypoglycemic agents

Causes of death

Septicemia with ketoacidosis

Electrolyte abnormalities

Silent MI

REFERENCE

DIABETES- MINIATLAS DIABETES FOOT DISEASEwww.diabetes.usyd.edu.auwww.diabetes-self-mgmt.comDIABETES MELLITUS –DR.P.G.RAMAN

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