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GPs go forth

Non-Covid clinical crises: Diabetic foot

Possible presenting scenarios

A new or worsening of pre-existing ulcer will present will the following:

  • Worsening exudate
  • Purulent discharge
  • Cellulitis
  • Gangrene (new or extending)
  • Pain (often no pain or very minimal increase in pain)

A new hot swollen foot without ulcer (and potential Acute Charcot Foot) will include:

  • Usually no ulcer
  • Erythema on the dorsum
  • Increase focal warmth
  • Recent trauma (but often no recollection of trauma)

What examination the GP should do

First, you should ascertain if this is a new problem or worsening of pre-existing issue.

Then:

  • Palpate pulses (dorsalis pedis and posterior tibial) or review available vascular assessment
  • Differentiate between: Mild infection (ulcer limited to subcutaneous tissue and erythema extends to >2 cm2 around ulcer); and more severe forms of infection (erythema extends to >2 cm2, tendon, muscle or joint exposed, systemic features present (flu-like symptoms, drowsiness, fever, tachycardia etc)
  • Look for new/worsening gangrene or extending tissue loss
  • Look for features of acute limb ischaemia (pale, pulseless, cold, paraesthetic/painful, weak limb)
  • Assess for features of systemic inflammatory response/sepsis
  • Consider the possibility of acute Charcot foot

What warrants immediate admission to hospital?

Reserved for those with limb or life-threatening features:

  • Acute limb ischaemia
  • Severe infection with necrosis requiring urgent debridement
  • Worsening foot with sepsis features (note concomitant risk of COVID19)

What requires urgent review in secondary care multidisciplinary foot service (MDFS)?

  • New ulcer – to allow clear planning including follow up strategies
  • Significant deterioration of pre-existing ulcer
  • New gangrene or necrosis but systemically stable
  •  features of chronic peripheral arterial disease have deteriorated within past 2 weeks
  • Any suspected acute Charcot foot

What the GP can/should do as a ‘holding measure’ if there is a delay in getting the patient seen (as there might be currently)

  • Treat infection promptly – Follow recommendations from NICE NG19 sections 1.6.7, 1.6.8 and 1.6.9.
  • Send a specimen (e.g. ulcer swab, tissue or pus) for up-to-date microbiology
  • Advice to rest the foot
  • Provide offloading to reduce pressure on the ulcer, where possible and available. Suggestions include semi-compressed felt with a donut cut-out around the ulcer or a standard off-loading shoe (e.g. Darco or Promedics shoes). Community foot protection units may help source them.
  • Organise follow up consultation in 48 -72 hrs – virtually if possible.
  • Involve community podiatry service for the frail - can they support with home visits and simple debridement?

Most MDFS are continuing to provide active essential service and can be contacted as per local pathways

Dr Prash Vas, is a consultant in diabetes foot medicine, King’s College Hospital, London

NICE NG19: https://www.nice.org.uk/guidance/ng19/chapter/Recommendations#diabetic-foot-infection

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