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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 Strict metabolic control- reg. insulin
Prompt RX of superficial fungal/
bacterial infections
TT prophylaxis
Grade 1 Rest the limb, avoid wt bearing
Ensure adequate drainage
Rinse with disinfectant and dry
dressing( no ointment)
Grade 2 Broad spectrum antibiotic
& above 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
THANK YOU