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 BOTH ACUTE- KETOACIDOSIS HYPEROSMOLARITY CHRONIC- MACROANGIOPATHY MICROANGIOPATHY NEUROPATHY COMPLICATIONS

DIABETIC FOOT PATHOGENESIS: 20%-NEUROPATHY 70%-NEUROISCHAEMIC 10%-ISCHAEMIC

TROPHIC ULCER ULCERATION 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 FOOT GR 1-SUPERFICIAL ULCER GR 2-DEEP ULCER,INFECTED,NO BONE INVOLVEMENT GR 3-DEEP ULCER, ABSCESS, BONE INVOLVED GR 4-LOCALISED GANGRENE GR 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 ulcer Intermittent claudicating Deformity-callus, claw toes, flat foot Loss of temp, discrimination, pain & vibration(at least 2) Evidence of haemodynamically significant PVD on investigation

Evaluation CLINICAL:

Sensory Motor Autonomic INVESTIGATIONS

CBP Blood and urine sugar Pus for c/s X-ray foot ECG, chest x-ray Others: LFT, urea, creat. ,electrolytes ,LL angio.

Prevention Diabetics not at high risk:

Foot care, file nails, wear comfortable well fitting shoes Stop smoking Aim for max glycaemic control Regular exercise

Diabetics at high risk: Inspect foot daily Report any lesion or suspected change of colour Never walk bare foot Wash feet daily…. Nail care Foot wear- MCR Do not expose feet to extremes of temperature

Management Grade 0

Grade 1

Grade 2 & above

Strict metabolic control- reg. insulin Prompt RX of superficial fungal/ bacterial infections TT prophylaxis Rest the limb, avoid wt bearing Ensure adequate drainage Rinse with disinfectant and dry dressing( no ointment) Broad spectrum antibiotic Local debridement of necrotic areas / I&D Frequent dressings

Management contd.. Tertiary level: Revascularisation procedures if significant ischaemia Amputation if the above measures fail and gangrene develops

IN OUR RHC Control of diabetes: sliding scale Control of infection: Culture and sensitivity, antibiotics multiple abscesses :- I & D Local treatment of diabetic foot: Healing :- cleaning & dressing Non- healing :- H2O2/ Ensol/ iodine sol Spreading :- debridement

General management Diabetic diet Exercise Oral hypoglycemic agents

Causes of death Septicemia with ketoacidosis Electrolyte abnormalities Silent MI

REFERENCE DIABETES- MINIATLAS DIABETES FOOT DISEASE www.diabetes.usyd.edu.au www.diabetes-self-mgmt.com DIABETES MELLITUS – DR.P.G.RAMAN

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