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Diabetic Foot ulcers Cheat Sheet by

Wound management focusing on diabetic foot ulcers.

History Taking

Chief complaint
Ask patient why they're here and take HPI (NLDOCAT)
Review Medica­tions
Ask if they are any changes. Ask about their taking behaviour and any side effects they may be experi­encing. Ask about compli­mentary or altern­ative medica­tions.
Review Allergies
Ask if they have any new allergies
Active Practi­tioners
Ask about any recent visits to specia­lists, including dental eyes, endroc­rine, nephron, neuro).
Medical History
Inquire about their condit­ions. Are they any new diagnoses?
 
Diabetes specific questions: date of diagnosis, FBG levels, A1C levels, recent hypogl­ycemia episodes, history of ulcers (if they are in for wound care, is this their first wound or have they had multiple?)
Social History
Inquire about their activity level. Are they working? Do they exercise? Do they live alone? Ask about smoking, alcohol and drug use.
Remember it is important to get a full picture of the patient as this will impact the treatment plan. Will they and are they able to change dressings? What may be impeding wound healing? Will the patient be compliant with the tx plan including offloa­ding. What is their financial situation? Can they afford approp­riate footwear or orthotics?

Wound Assessment

Vascular Testing
Inquire the last time they have had any vascular testing. This should be done once a year if they have circul­atory insuff­ici­encies or are high risk. Check pulses, cap refill. Skin/hair assessment for venous or arterial insuff­ici­ency, assess for swelling- Does the patient wear compre­ssion stockings? Inquire about IC night or rest pain. Do we need to take temper­ature or use doppler. Conclude their overall vascular status and what this means regarding wound healing.
Neurol­ogical Testing
Monofi­lament, vibration, propri­oce­ption and assess small diameter fibres. Inquire about any pain or sensation (burning, tingling, etc). Conclude neurol­ogical status, does this contribute to the cause or wound healing?
Examin­ation of Wound
Duration of the wound, change in size/a­ppe­arance, change in number of wounds, pain or altered sensation with wound. Does the patient know the cause of the wound? Ask about systemic signs as well (lethargy, flu, malaise, etc). Look for signs of infection. Note the periphery of the wound is it callused or macerated? Look for exudate. Inspect the wound bed for granul­ation tissue, note the colour of the base. Note the depth-PTB? Take temper­ature! Compare to contra­lateral side.
Deformity
Look for any deform­ities or areas of pressure
Skin
Look for evidence of skin breakdown. More areas at risk for ulcera­tion?
Footwear
Assess footwear.
Use Diabetic inlow's screening tool. Decide how often the patient needs to be screened. If they are diabetic and have history of ulcer/­amp­uta­tion, need to screen every 1-3 months. LOPS w/wout PAD/de­for­mit­y/o­nyc­hom­yco­sis­/ev­idence of pressure need to be screened every 3-6 months. If low risk needs to be screened once yearly.

PEDIS Wound Classi­fic­ation

PEDIS- Perfusion, Extent, Depth, Infection, Sensation

Wound Types

Healing: Causes and co-factors that can interfere with healing have been removed. Wound healing occurs in a predic­table fashion. Wound may be acute or chronic.
Non-he­aling: Wound has healing potential, but causes and co-factors that can interfere with healing have not yet been removed.
Non-he­alable: Causes and co-factors that can interfere with healing cannot be removed (e.g., in cases of terminal disease or end-of­-life care).

Texas Wound Classi­fcation

Diagnostic Tests

Swab Technique
1. Rinse wound with normal saline. 2. Do not swab pus. exudate, hard eschar or necrotic tissue. Rotate the swab tip (sterile cotton tip) in an area of clean granul­ation tissue for 5 seconds, using enough pressure to release tissue exudate. Warn patient for pain. 3. Remove protective cap from culture medium and insert cotton tipped applicator into the culture medium. 4. Transport to lab within 24 hours.
Culture & Sensit­ivity
Entire petri dish surface is inoculated with test organism and an antibiotic impreg­nated disc containing a range of abx is paced on the surface. Inhibition of the growth around the disc indicates sensit­ivity of the organism to the abx.
Cellulitis
CBC W/diff, ESR/CRP, C&S, biopsy, x-rays, bone scans, MRI/CT­/ul­tra­sound

Osteom­yelitis in Diabetics

Contiguous Focus OM
Soft tissue infection directly extends into adjacent bone. Most common OM in LE.
 
X-rays- shows swelling, gas bubbles, mottled bony osteolysis and sclerotic areas (late finding)
Direct Extension
Puncture wounds, retained foreign body, puncture through shoe (s.aurea, p.aeru­ginosa)
OM Secondary to Vascular Insuff­ciency
Caused by arteri­osc­ler­osis, diabetics with arterial disease or frostbite
Physical Examin­ation
Focus on locating a nidus of infection, assessing PVD and sensory function and exploring ulcer of bone.
Diagnosis
X-ray (need 30-50% of mineral content loss to show on image). First sign is gas in tissue, if gas, then x-ray alone is enough for diagnosis. Also see soft tissue swelling.
 
MRI. Gold standard as it is most sensitive and specific. Can detect change in compos­ition of bone marrow early on.
 
Bone biopsy with bacterial culture is gold standard for OM in diabetic patients.
Diagnostic Criteria
Exposed bone, persistent sinus tract, tissue necrosis overlying bone, chronic wound over hardware or fracture.
Treatment
Many will need surgery and prolonged abx.
 
Oral therapy may be just as effective as IV therapy. Ciprof­loxacin is most used.
 
Immediate referral to hospital. (Infec­tious disease specia­list, IV abx and maybe surgical interv­ent­ion).
Ask patient about systemic symptoms (lethargy, malaise, back pain, fever). Think about predis­posing factors (diabetes, PVD, trauma, IV drug use).

Wagner Wound Classi­fic­ation

Adjunctive Therapies for Wound Healing

Negative Pressure Wound Therapy
Controlled negative pressure over the wound surface
 
Facili­tates the drainage of the fluid and debris, reducing bacterial counts and edema and increasing capillary blood flow and granul­ation tissue formation.
 
Considered for healable wounds that are stalled and the exudate is greater than what can be managed with conven­tional advanced dressing modalities
Hyperbaric Oxygen Therapy
Admini­str­ation of 100% O2 at an increased atmosp­heric pressure to a wound
 
Improves tissue oxygen­ation, down regulates inflam­matory cytokines, up-reg­ulates growth factors, antiba­cterial and leukocyte effects
Topical Wound Oxygen Therapy
Admini­str­ation of pressu­rized oxygen topically to the wound bed
 
Supplies continuous or cyclical diffusion of pure oxygen over the surface wound
 
Increase vascular endoth­elial growth factor expression and blood vessel density
Electrical Stimul­ation
Applic­ation of capacitive coupled electrical current to transfer energy to a wound.
 
Increased blood flow and oxygen­ation, edema and pain reduction, debrid­ement, thromb­olysis, bacter­icidal, faster wound closure, improved scar formation
Ultrasound
Applic­ation of ultrasound waves to the wound/­per­-wound to induce cellular activity
 
Increases the release of growth factor­s/f­rib­rob­lasts, accele­rates the inflam­matory phase and wound contra­ction, increases vascul­arity, improves wound tensile strength and elasti­city, reduces pain and edema, reduces bruises and hematoma, bacter­icidal
Shock Wave
Shock waves targeted directly to the wound area to speed healing. Promotes the generation of new connective tissue, has an analgesic effect for pain reduction and facili­tates blood flow to the area.
Intern­ational best practice guidelines identifies adjunctive treatments such as negative pressure wound therapy and hyperbaric oxygen therapy may be considered if approp­riate but requires advanced clinical decisi­on-­making skills.
  

Popular Wound Dressings

Promogran Prisma
Maintains a physio­log­ically moist enviro­nment at the wound surface that is conducive to granul­ation tissue formation, epithe­lia­liz­ation and optimal wound healing.
 
Contains silver and antimi­crobial agents
 
Sterile, freeze dried composite of oxidized regene­rated cellulose, collagen and silver
 
In the presence of exudate, the prisma transforms into a soft and confor­mable biodeg­radable gel allowing contact with all areas of the wound
 
ORC helps with tissue repair, cell growth and control bacteria growth
Silvercel
Non-ad­herent antimi­crobial alginate dressing
 
Has carboxy methyl­cel­lulose & silver. Easy to lift technology
 
Sustained release of silver ions up to 7 days-> effective barrier protec­tion. Good exudate manage­ment, maintains moist enviro­nment.
Acticoat
Antimi­crobial barrier dressing consists of three layers: an absorbent rayon/­pol­yester inner core sandwiched between outer layers of silver coated, low adherent polyet­hylene net.
 
Helps maintain moist enviro­nment at the wound surface and has barrier protection for at least 3 days.
Inadine
Impreg­nated with polyet­hylenge base containing 10% Povidone iodine that has a broad spectrum of antimi­crobial action.
Biofilms are complex microbial commun­ities, containing bacteria and sometimes also fungi, which are embedded in a protective polysa­cch­aride matrix. The matrix attaches the biofilm to a surface, such as a wound bed, and protects the microo­rga­nisms from the host's immune system and from antimi­crobial agents such as antise­ptics and antibi­otics. Biofilms are commonly present in chronic wounds, and are thought to contribute to, and perpet­uate, a chronic inflam­matory state that prevents healing

Wound Dressings

Conven­tional
Gauze. Non woven better than woven as it is more absorp­tive. Does have strike through, adherence and incorp­oration into wound surface
Transp­arent films
Semipe­rmeable adhesive films- Opsite, Tegaderm. Permeable to gas and water vapour but not to water, no fibres, transp­arent, non absorbent
Low Adherent Wound Contact Layers
Non medicated: Adaptic or Mepitel. Medicated: Bactrigras tulle which contains chlorh­exidine acetate, Inadine
Low Adherent Absorbent Dressings
Melolite (highly absorbent cotton and acrylic fibre pad and polyester film). Has rapid drainage of exudate, reduces trauma to healing tissue, very absorbent, comfor­table, minimizes pain on removal.
Semipe­rmeable Hydrogels
Intrasite gel. Contains carbox­yme­thy­lce­llu­lose.
Hydroc­olloids
Tegasorb, comfeel, duoderm. Form a gel when in contact with wound surface. Semi liquid produced provides moisture and insulated enviro­nment, occlusive. Contra­ind­icated in infected wounds. Not good for diabetic ulcers.
Hydrofiber Wound Dressings
Aquacel. Moderate to heavily exudating wounds.
Alginate Dressings
Kaltos­tat­-Ca­lcium Sodium Alginate. Calcium and sodium salts of alginic acid, derived from seaweed. When in contact with blood or exudate, alginate fibers convert into a hydrop­hilic gel. Gel is absorbent, protective moist interface with the wound. Indicated for moderately to highly exuding chronic and acute wounds and for wounds with minor bleeding.
Polyur­ethane Foams
Allevyn- moderate amounts of exudate. Allows adequate hydration of the wound surface and has effective thermal insula­tion.
Charcoal Dressing
Malodorous exudating wounds. Deodorant dressing with activated charcoa.
Silver agents
Antiba­cte­rial. Acticoat and silvercel. Usually a combin­ation dressing.
Deslou­ghing Agents
Iodosorb. Exerts hydrop­hillic action, acting as an absorbent, also helps remove debris and bacteria from wound surface by capillary action, beads swell under the influence of exudate and the release of iodine. Intrasite gel, products with enzymes, sterile larvae can also be used for slough.

Offloading

Total Contact Cast
Gold standard! Contra­ind­icated for infected or ischemia wounds.
Removable Cast Walker
Not for heel ulcers. Can be used for infected wounds. Not good for those with poor balance
Instant Total Contact Cast
Not for heel ulcers. May not be tolerable
Half shoe (Rearfoot or forefoot)
Either good for heel or toe/fo­refoot ulcers. Very unstable
Surgical Shoe
Best for forefoot but can be used for all locations. Low cost. Use with orthotic. Good for edema. Only for short term.
OTC or custom orthot­ics­/fo­otwear
Distri­butes pressures evenly but expensive
Padding
Low cost but offloading property limited.
Surgical Offloading
Achilles tendon length­ening, joint arthro­plasty met head resection or osteotomy can support healing and prevent future ulcer if conser­vative treatment fails
 
Cannot be done in ischemia patients or uncont­rolled infection
 
Digital flexor tenotomy used to prevent or support healing of toe ulcer when conser­vative tx fails
When choosing offloading device, consider- disease, pressures, ulcer location, type and dressing, physical activity, finances, patient behaviour (ability to adhere to plan/m­ental capabi­lities)

Surgeries- Amputa­tions and Revasc­ula­riz­ation

Revasc­ula­riz­ation:
Angiop­lasty- Using a ballon and/or stent to widen the artery
 
Athrectomy - Clear out the plaque that is causing the occlusion
 
Bypass Surgery- Surgeon uses a graft of a blood vessel to reroute blood flow around a blockage.
 
Endart­ere­ctomy- Surgeon opens artery to remove plaque buildup inside.
Amputation:
Causes: trauma, ulcers (persi­stent, decreasing quality of life, necrosis), infection, vascular, deformity
 
Digital- Performed due to extensive ulcera­tion. OM or gangrene. Semi-e­lli­ptical incisions carried down to bone. Cartilage on met head better barrier to infection so we don't cut bone in middle. Auto amputation (2-6 months) good for those who shouldn't have surgery
 
Ray amputa­tions- central, 1st or 5th. Performed for abscess, OM, or necrot­izing fasciitis. Converging semi elliptical incisions around base of toe. Met is exposed and resected at point where bone does not appear infected. May have transfer lesions.
 
Midfoot amputa­tions- Transmet (will do TAL to decrease FF pressu­res). Lisfranc (less stable, equino­varus)
 
BKA better than doing syme or chopart amputa­tions.
 

Factors that affect Wound Healing

Glycemic level
Trauma
Activity
Neuropathy
Smoking
Bony deformity
Footwear
PAD
History of wounds
Amputa­tions
Age
Other infections in body

Smoking and Diabetes

-Smoking alters blood glucose homeos­tas­is-> increases blood glucose
-Smoking can decrease insulin action and impairs measures of B cell function
- Exposure to cigarette smoke is associated with vascular damage, endoth­elial dysfun­ction and activation of the blood-­clo­tting cascade.
-Cigarette smoking increases risk of micro and macrov­ascular compli­cations in diabetes
-Smoking cessation should improve glycemic control but cessation often worsens glycemic control, possibly due to weight gain that often occurs after smoking abstin­ence. Emphasize the importance of both exercise and smoking cessation together!

Short-Term Management Plan

Assessment and Classi­fic­ations
Do approp­riate assess­ments and classify wounds. Is this mild/m­oderate or severe and needs hospit­ali­zation right away? Do we need to refer to vascular studies right away? Consider doing ABI and TBI.
Treatment
Cleanse. (chlor­ohe­xidine gluconate 2%), providone iodone, wound cleanser, sterile saline)
 
Sharps debrid­ement. Tissue nippers are great to use for undermined edges and it doesn't hurt the patient.
 
Cleanse again. Use antise­ptic, mostly like sterile saline. Pat dry.
 
Apply antise­ptic. Betadine most commonly used.
 
Dressing. Choose approp­riate dressing that will remove exudate and maintain humidity. Want it to have low adherence and maintain a good temp. Maintain suitable pH and be permeable to gases NOT microo­rga­nisms. Think about the comfort and ease for patients.
Advice
Dressing instru­ctions, activity reduction, protecting wound from trauma and while showering. Instruct how to monitor for signs of infection. Tips to keep skin overall healthy.
Social History
Understand any underlying factors that may put patient at risk for infect­ions. Such as, UTI, age, mobility, psycho­social factors, self-care ability

Mid-Te­rm/­Sho­rt-term Management Plan

Reasse­ssment
Reassess wound along with dressing and offloa­ding- do we need to make changes?. Abx? culture & sensit­ivity? imaging?
 
Asking the patient what they're doing at home. Decreasing or increasing activity? Home care? Do they feel the wound is getting better? Are they wearing offloading devices?
 
Re-che­cking vascular status
 
Assessing medica­tions, is it impairing wound healing? (ie steroids)
Advanced Therapies
Think about adjunctive therapies and dressings that may be beneficial for the patient.
Surgical Referral
Foot recons­tru­ction, tenotomy, arthro­plasty, etc, vascular surgeries
Other Referrals
Nutrit­ionist for nutrition screening, endocr­ino­logist, etc)
Most of these we would implement in the short-­term. Mid-term should focus on preventing infect­ion­/re­ducing risk factors for infection.

Long-Term Management Plan

Long term goals: PREVEN­TION! If the wound is closed, how do we ensure we are preventing it from occurring again? Streng­thening our circle of care. Referrals for smoking cessation, nutrition management and psycho­social should be made. Including the patient in the long-term plan. What can THEY do to prevent reulce­ration. When should they be concerned? Advise joining support groups.
If the wound isn't closing, consider referring to infectious disease specia­list. Start from the basics (short­-term plan)

Antibi­otics

Cephalexin or TMP/SMX is 1st line of treatment for cellulitis seen in the diabetic foot. 2nd line is cloxac­illin.
Even though most DFU infections are caused by staph and step. Look for signs of pseudo­monas (Green ring or odour). In this case, prescribe Ciprof­lox­acin.
If there is a penicillin allergy or renal insuff­ici­ency, consider clinda­mycin
Foul smell or presence of necrotic tissue may indicate anaerobes - use clinda­mycin or amoxic­ill­in/­cla­vul­anate.
When you have doubt regarding the probable organism, go with cephal­exin!
If CA-MRSA is cultured, go with TMP/SMX.
       
 

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  • Published: 14th April, 2022

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