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:

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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