Emergency management of the acute diabetic foot

Abstract

The foot of a person with diabetes is at risk for a number of reasons. Neuropathy is common, particularly if diabetes is long-standing and glycaemic control has been poor. Not only does the neuropathy reduce sensation and result in deformity, making the foot susceptible to injury, but the autonomic component may cause arteriovenous shunting and other micro-circulatory changes, which result in reduced nutritional skin perfusion, despite a foot that may look pink and feel warm. Initially the patient may be unaware of the developing wound. Peripheral arterial disease affecting the main arteries of the lower limb is four times more common in people with diabetes. This may have previously been recognized, causing symptoms such as intermittent claudication, but is often asymptomatic, only becoming apparent when a minor wound on the foot fails to heal. The foot of a person with diabetes then is prone to injury and ischaemia which reduces the chances of wound healing. Unlike non-diabetic patients they are more susceptible to infection and it is often the infection that results in emergency or urgent presentation (Frisch et al., Diabetes Care 33:1783-1788, 2010). Patients may present with pain, swelling, tissue loss, a hot (infected) or cold (ischaemic) foot and may have generalized symptoms of sepsis including fever, nausea and vomiting. In this chapter, we focus on patients presenting with a red, hot, infected diabetic foot. Early recognition and management of diabetic foot problems is essential, as delays increase morbidity, mortality and the need for amputation. It should be clear which clinical team and consultant are responsible for the patient and the care pathway can be divided into immediate care, care between 4 and 48 h and ongoing care (Putting Feet First. June 2009. www.diabetes.uk.org.uk). There should be an agreed management plan for this condition that can be followed by all members of the health care team.