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Emergency Med > 8 - Surgical Management of Foot Infection > Flashcards

8 - Surgical Management of Foot Infection Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Objectives

A
  • Evaluation and management of foot infections requiring surgical treatment.
  • Current IDSA guidelines for diabetic foot infections.
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2
Q

Indications for surgical interventions

A
  • Abscess
  • Osteomyelitis
  • Gas Producing infection = Medical emergency
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3
Q

Good info to get in the history

A

o Speed of onset and duration
o Trauma
o Sources of contamination of wound
o Pain – particularly in insensate person
o If likely surgical case, when person last ate or drank

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4
Q

Good info to get in the ROS

A

o F/C/N/V
o Recent blood glucose

Review drug allergies

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5
Q

Physical exam

A

o Palpable fluctuance, or crepitance
o Lymphangitic streaking
o Mark leading edge of erythema
o Vitals

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6
Q

X-rays

A

o Look for gas, foreign bodies, signs of osteomyelitis

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7
Q

Labs to get

A

o WBC, CMP

o ESR or CRP

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8
Q

IDSA (infectious disease society of America) Diabetic Foot Infection Classification

A
  • Uninfected
  • Mild
  • Moderate
  • Severe
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9
Q

Uninfected

A

o Wound without purulence or any manifestations of inflammation

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10
Q

Mild

A

o Cellulitis or erythema > 0.5cm to ≤2 cm around ulcer or wound
o Infection is limited to skin or superficial subcutaneous tissue
o No local complications or systemic illness
o ***Should exclude other causes of inflammation (e.g., trauma, gout, acute Charcot, fracture, thrombosis, venous stasis)

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11
Q

Moderate

A

o Erythema >2 cm, OR involving deeper structures than skin or subcutaneous tissue (e.g. abscess, osteomyelitis, septic arthritis, fasciitis)
o AND no systemic inflammatory response syndrome (SIRS)

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12
Q

Severe

A

Local infection (as described previously) with signs of SIRS as manifested by ≥2 of the following:

  • Temperature > 38°C or 90 beats/min
  • Respiratory rate >20 breaths/min or PaCO2 12,000 or
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13
Q

IDSA validation - full thickness

A

This is how often each grade of the IDSA scale leads to a full thickness wound (no deeper):

  • No infection: 88.7%
  • Mild infection: 76.1%
  • Moderate infection: 30.8%
  • Severe infection: 22.2%
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14
Q

IDSA validation - fascia or tendon

A

This is how often each grade of the IDSA scale probes to fascia or tendon (no deeper)

  • No infection: 7.2%
  • Mild infection: 21.1%
  • Moderate infection: 25.0%
  • Severe infection: 11.1%
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15
Q

IDSA validation - bone or joint

A

This is how often each grade of the IDSA scale probes to bone or joint:

  • No infection: 4.1%
  • Mild infection: 2.8%
  • Moderate infection: 44.2%
  • Severe infection: 66.7%
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16
Q

IDSA validation - bone infection

A

This is how often each grade of the IDSA sale leads to bone infection

  • No infection: 0%
  • Mild infection: 0%
  • Moderate infection: 38.5%
  • Severe infection: 37%
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17
Q

Graph on hospitalization and amputation rates based on the IDSA grade of infection

A
  • No infection: very few hospitalizations, very few amputations
  • Mild infection: 10% are hospitalized, very few amputations
  • Moderate infection: 55% are hospitalized, 45% have amputations
  • Severe infection: 90% are hospitalized, 75% have amputations
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18
Q

Causative organism for cellulitis without open skin lesion

A
  • Staph aureus

- Beta hemolytic strep

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19
Q

Causative organism for infected ulcer, antibiotically naive

A
  • Staph aureus

- Beta hemolytic strep

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20
Q

Causative organism for infected ulcer, previously treated

A
  • Staph aureus
  • Beta hemolytic strep
  • Enterobacter
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21
Q

Causative organism for macerated ulcer due to drainage or soaking

A
  • Pseudomonas

- Polymycrobial

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22
Q

Causative organism for long standing ulcer with prolonged broad spectrum antibiotic use

A
  • Polymycrobial
  • Staph aureus
  • Beta hemolytic
  • Pseudomonas
  • Gram negative rods
  • Resistant bacteria
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23
Q

Causative organism for “fetid foot” - extensive necrosis or gangrene

A
  • Gram positive cocci
  • Gram negative rods
  • Obligate anerobes
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24
Q

Causative organism for osteomyelitis

A
  • Staph aureus

- Pseudomonas (puncture wounds)

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25
Q

Clinical signs of MSSA

A

o Thick, yellow, purulent drainage

26
Q

Clinical signs of MRSA

A

o Usually quicker onset of purulent producing infection

27
Q

Clinical signs of Strep

A

o Deeper red infection than staph and not as purulent

28
Q

Clinical signs of pseudomonas

A

o Fruity smell

o Green tinge to wound

29
Q

Clinical signs of anaerobes

A

o Extreme foul smell

o Brown, watery discharge

30
Q

IDSA suggested antibiotics for moderate to severe foot infections with MSSA, streptococcus, enterobacteria and obligate anaerobes

A

1 = Ampicillin-sulbactam (Unasyn)
- This is adequate if low suspicion of pseudomonas

2 = Ertapenem
- Once daily dosing, relatively broad spectrum, not active against pseudomonas

3 = Imipenem-cislastin
- Very broad spectrum (no MRSA coverage) only use when needed

31
Q

IDSA suggested antibiotics for moderate to severe foot infections with MRSA

A

Vancomycin

32
Q

IDSA suggested antibiotics for moderate to severe foot infections with pseudomonas aeruginosa

A

Piperacillin-tazobactam (zosyn)

- TID or QID dosing, but good broad spectrum coverage

33
Q

Case study HPI

A

o 53 year old female admitted to hospital by PCP for diabetic foot infection
o PCP noted larger bulla on plantar right midfoot with foul drainage
o Pain on foot and leg
o Fever (102 degrees F), chills, nausea, vomiting

34
Q

Case study ROS

A 
o	Last blood glucose 200-300 
o	A1c 8-10
o	Numbness in hands and feet 
o	Blurred vision secondary to retinopathy 
o	Heart palpitations for 2 days
35
Q

Case study PMHx

A

o Type 2 diabetes

o Renal failure with dialysis

36
Q

Case study physical exam

A 
o	Vascular: pedal pulses palpable 
o	Neuro: diminished
o	Foot: hot, swollen, erythematous foot 
o	Derm: large bulla the width of the plantar arch with gray/black in color with small opening centrally. Erythema to surrounding tissue, no purulent drainage 
o	Musculoskeletal: pain with palpation

X-ray
o Gas gangrene in the medial arch
o Make sure it isn’t tracking up into the leg (this stays mostly in the arch, medial to lateral)

Culture
o Either culture drainage in the ER or do it in the OR

37
Q

Labs yesterday and labs today

A 
-	Labs yesterday (CRP, ESR, WBCs)
o	WBC = 29.5 (10 is normal) 
o	H/H = 10.6/31 
o	Bun/Cr = 86/6.2 
o	Blood glucose = 294
o	Albumin = 3.2 
o	C-reactive protein = 24.1 (1 or less is normal)
38
Q

Treatment

A

Emergency I & D
o Infections will more commonly track up tendons
o Less commonly it will track across the arch
o Can see the plantar fascia
o Use bag of 300 mL of saline and wash it out with pressure lavage

39
Q

Dressing

A

o Pack the wound
o Do not close the wound because it would increase an anaerobic environment
o Let it drain then go back a few days later

40
Q

Cultures

A 
o	Staph aureus 
o	Strep (GBS)
o	Bacteroides 
o	MRSA 
o	Enterobacter
41
Q

Repeat I & D

A

o Back to OR for repeat
o Continued purulent drainage
o Intraoperative findings = necrotic tissue found within wound
o Purulent drainage from multiple deep pockets
o Wound VAC applied in OR

42
Q

Management going forward

A

o Diabetes
o Living situation with help
o WB, antibiotics

43
Q

Discharge from hospital

A

o Patient sent to SNF for wound vac therapy and 4 weeks IV abx (vanc, zosyn) per ID recommendation
o Wound eventually healed

44
Q

CASE STUDY 2

A

o 51 year old male presents to clinic with ulcer plantar left hallux
o Went on fishing trip 1 month ago, ulcer formed from wet, rubbing boots
o 10 days ago noticed erythema and edema
o 4 days ago went to ED and was put on ED

45
Q

Case study PMHx

A

o T2D, HTN
o Heart murmur
o High cholesterol, colon cancer hx

46
Q

Case study social

A

o Denies tobacco, alcohol, drug use

o Counselor at prison system

47
Q

Case study ROS

A

o Denies fever, chills, nausea, vomiting
o Blood glucose around 120, does not check often due to
o Some numbness and tingling in the feet
o Does not feel like feet are hot or cold (vascular)
o Denies claudication
o Had ulcers before? Did they heal?

48
Q

Case study physical exam

A

o Pedal hair present
o Pedal pulses are not palpable but are biphasic with Doppler and pedal hair is present
o Cannot feel monofilament (2/10)
o Size of ulcer is 2 mm in diameter
o Derm: erythema noted to lef hallux with slight purpule discoloration
o Ulcer plantar hallux IPJ with yellow fibrotic base
o Edema present to hallux and foot
o Musculoskeletal: ROM is somewhat limitied to 1st MPJ, pain to palpation of the hallux, no fluctuance or crepitus

49
Q

Case study initial visit

A

o Purple discoloration from infection
o Get x-ray, take culture, get bloodwork
o Antibiotics are not currently helping
o Vascular studies (did not get them because circulation was pretty good)
o Offloading (total contact cast, boot, post-op shoe, cutout over 1st ray)
o Dress the wound, does not meet criteria to put in the hospital

50
Q

Cultures

A

o Group G strep
o MSSA

Bactrim
o Bactrim only covers staph and usually MRSA
o Bactrim does NOT cover strep very well – not great

51
Q

X-rays

A

o No gas present

o No erosive changes in bones (no osteo)

52
Q

1 week later

A

o Toe started turning gray 2 days after being seen
o Presents with completely black toe
o Needs amputation right away
o Progressed so quickly so be suspicious of necrotizing fasciitis

53
Q

Hospital

A

o Admit to hospital
o X-rays
o Labs
o Amputation

54
Q

Labs at hospital

A

o WBC = 12.7
o Sed rate = 100
o CRP = 7.5
o AbA1c = 8.1

55
Q

Treatment

A

o Hallux amputation performed
o Cultures came back as skin flora
o Patient send home non-weight bearing

56
Q

4 weeks post op

A

o Sutures removed because they were loose
o Minimal drainage
o No pain
o Would like to go back to work

57
Q

6 weeks post op

A

o Patient called in stating he can see bone
o Instructed to use betadine and call if redness or signs of systemic
o Wound came open 1-2 weeks after going back to work

58
Q

How to manage now

A

o X-rays
o 1st ray amputation or partial first ray amputation
o Admit to hospital
o MRI to see extent of bone involvement (1st met head is destroyed, Edema goes back to base of 1st met head, Infectious disease wanted the whole 1st ray to be gone)
o Biomechanics (If you take off the whole first ray, he will have no attachment for Lis francs TA, more pressure on other metatarsals)

59
Q

2 weeks later

A

Healing well at this time

60
Q

Case study 3

A
  • 52-year-old diabetic male with new ulcer plantar 2nd metatarsal head
  • Chills nausea
  • Vascular -= DP palpable, PT not, glucose 765
  • 2nd ray is already missing
  • High BP, high pulse, high respirations
  • Admitted to hospital right away
  • X-rays – Soft tissue gas

Emergency Med (14 decks)

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