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1362465385 managinig neuropathic ulcer skke (1)

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managinig neuropathic ulcer skke (1)

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1362465385 managinig neuropathic ulcer skke (1)

  1. 1. 1 Daily Foot ExaminationDaily Foot Examination • Check For:Check For: • BlistersBlisters • BleedingBleeding • InjuryInjury • SmellSmell • Increased temperature at pressure pointIncreased temperature at pressure point
  2. 2. 2 Management of NeuropathicManagement of Neuropathic Ulcer - 1Ulcer - 1 – General measuresGeneral measures – Specific measuresSpecific measures
  3. 3. 3 Management of NeuropathicManagement of Neuropathic Ulcer - 2Ulcer - 2 • Good glycemic controlGood glycemic control • Treatment of infectionsTreatment of infections • Management of neuropathic oedemaManagement of neuropathic oedema
  4. 4. 4 Management of NeuropathicManagement of Neuropathic Ulcer - 3Ulcer - 3 • All ulcers irrespective of their cause willAll ulcers irrespective of their cause will be slow to heal in presence of oedema,be slow to heal in presence of oedema, due impairment of local flowdue impairment of local flow • Neuropathic oedema can be treatedNeuropathic oedema can be treated withwith – DiureticsDiuretics – Ace inhibitorsAce inhibitors – Ephedrine ( 30 mg tds )Ephedrine ( 30 mg tds ) – D/d: hypoalbuminemia cardiacD/d: hypoalbuminemia cardiac
  5. 5. 5 Management of NeuropathicManagement of Neuropathic Ulcer - 4Ulcer - 4 • ““Over 90% of predominantly neuropathicOver 90% of predominantly neuropathic • ulcers will heal satisfactorily withulcers will heal satisfactorily with • conservative measures”conservative measures”
  6. 6. 6 Management of NeuropathicManagement of Neuropathic Ulcer - 5Ulcer - 5 • ““Key to the management is the relief ofKey to the management is the relief of • pressure that caused the initial lesion”pressure that caused the initial lesion” • Pressure is off loaded most effectivelyPressure is off loaded most effectively byby • encasing the foot in a light plaster ofencasing the foot in a light plaster of parisparis • cast.cast. – *Total contact cast*Total contact cast
  7. 7. 7 • You can put almost anything on theYou can put almost anything on the ulcer except the patients weight – saysulcer except the patients weight – says the Australian Podiatristthe Australian Podiatrist Management of NeuropathicManagement of Neuropathic Ulcer - 6Ulcer - 6
  8. 8. 8 Foot at risk - 1Foot at risk - 1 • Our job – look after “NDF at risk”Our job – look after “NDF at risk” • A: Preventive measuresA: Preventive measures • Treatment - rapid and intensiveTreatment - rapid and intensive • RestRest • Off loadOff load • AntibioticsAntibiotics • Foot wearFoot wear • Patient educationPatient education
  9. 9. 9 Foot at Risk - 2Foot at Risk - 2 • B. Metabolic controlB. Metabolic control – HyperglycemiaHyperglycemia – HypertensionHypertension – HyperlipidaemiaHyperlipidaemia – Cessation of smokingCessation of smoking • C. Deformity managementC. Deformity management • D. Callus managementD. Callus management • E. Debridement and dry skin and fissureE. Debridement and dry skin and fissure
  10. 10. 10 Foot at risk - 3Foot at risk - 3 • F. Mechanical controlF. Mechanical control – Off load, Off load, Off loadOff load, Off load, Off load • by rest, crutches, walkers, protective shoes,by rest, crutches, walkers, protective shoes, heel protective pad, decrease plantarheel protective pad, decrease plantar pressure by removal calluspressure by removal callus • G. The importance of callus removal in NFUG. The importance of callus removal in NFU • decrease plantar pressuredecrease plantar pressure • shows full dimension of the ulcershows full dimension of the ulcer • deep swab possibledeep swab possible • drainage of exudate, removal of dead tissuedrainage of exudate, removal of dead tissue • H. Infection controlH. Infection control • I. Educational controlI. Educational control
  11. 11. 11 Acute Chronic Assess Assess vascular Status Vascular status A/B index > 0.7 Peripheral pulses A/B Index Assess Extent weak / not palpable > 0.7 of Infection A/B index < 0.5 Localised wound Deeper Inf. No Charcot Charcot Foot Colour Doppler CT Scan Conservative Treatment Dedridement on Rule out MRI Complete rest Angiography Anatomical Principles Osteomyelitis Nuclear plaster cast scan antibiotics Revascularization Revacularization Dressing Contact Surgery not feasible off loading cast CT. off loading Strict & POP cast Surgery Angioplasty Gene Therapy Higher Amputation Rehab Reconstruction off loading Till stage of Footwear dressing reformation Ischaemic pain No ischaemic pain Prolonged Gradual antibiotic cover Mobilisation Strict off loading Gradual Foot wear Auto amputation Mobilisation restricted Activity Foot wear SURGICAL TREATMENT OF Assess Neuropathy Rule out Charcot Foot WOUND DIABETIC FOOT By Dr. Arun Bal
  12. 12. 12 Preventing Neuropathic FootPreventing Neuropathic Foot Ulcers - 1Ulcers - 1 • Regular inspection of foot - annuallyRegular inspection of foot - annually • Identification of high risk feet – 3 mo / 6moIdentification of high risk feet – 3 mo / 6mo • Careful choice of foot wearCareful choice of foot wear • Regular chiropodyRegular chiropody • Intense educationIntense education
  13. 13. 13 Preventing neuropathic footPreventing neuropathic foot ulcers - 2ulcers - 2 • ““As little as one hour’s educationAs little as one hour’s education provided by the podiatrist resulted in 70%provided by the podiatrist resulted in 70% reduction in amputations over thereduction in amputations over the following 2 years . as compared with afollowing 2 years . as compared with a control group who did not receive thecontrol group who did not receive the advice”advice”  Malone IM et al 1989Malone IM et al 1989
  14. 14. 14 Glycemic control and diabeticGlycemic control and diabetic neuropathyneuropathy • Diabetes control and complication trialDiabetes control and complication trial • showed that intensive insulin therapyshowed that intensive insulin therapy • reduced the incidence of appearance ofreduced the incidence of appearance of • neuropathy by about 70%neuropathy by about 70%
  15. 15. 15 Daily Foot ExaminationDaily Foot Examination • Check For:Check For: • BlistersBlisters • BleedingBleeding • InjuryInjury • SmellSmell • Increased temperature at pressure pointIncreased temperature at pressure point
  16. 16. 16 Management of NeuropathicManagement of Neuropathic Ulcer - 1Ulcer - 1 – General measuresGeneral measures – Specific measuresSpecific measures
  17. 17. 17 Management of NeuropathicManagement of Neuropathic Ulcer - 2Ulcer - 2 • Good glycemic controlGood glycemic control • Treatment of infectionsTreatment of infections • Management of neuropathic oedemaManagement of neuropathic oedema
  18. 18. 18 Management of NeuropathicManagement of Neuropathic Ulcer - 3Ulcer - 3 • All ulcers irrespective of their cause willAll ulcers irrespective of their cause will be slow to heal in presence of oedema,be slow to heal in presence of oedema, due impairment of local flowdue impairment of local flow • Neuropathic oedema can be treatedNeuropathic oedema can be treated withwith – DiureticsDiuretics – Ace inhibitorsAce inhibitors – Ephedrine ( 30 mg tds )Ephedrine ( 30 mg tds ) – D/d: hypoalbuminemia cardiacD/d: hypoalbuminemia cardiac
  19. 19. 19 Management of NeuropathicManagement of Neuropathic Ulcer - 4Ulcer - 4 • ““Over 90% of predominantly neuropathicOver 90% of predominantly neuropathic • ulcers will heal satisfactorily withulcers will heal satisfactorily with • conservative measures”conservative measures”
  20. 20. 20 Management of NeuropathicManagement of Neuropathic Ulcer - 5Ulcer - 5 • ““Key to the management is the relief ofKey to the management is the relief of • pressure that caused the initial lesion”pressure that caused the initial lesion” • Pressure is off loaded most effectivelyPressure is off loaded most effectively byby • encasing the foot in a light plaster ofencasing the foot in a light plaster of parisparis • cast.cast. – *Total contact cast*Total contact cast
  21. 21. 21 • You can put almost anything on theYou can put almost anything on the ulcer except the patients weight – saysulcer except the patients weight – says the Australian Podiatristthe Australian Podiatrist Management of NeuropathicManagement of Neuropathic Ulcer - 6Ulcer - 6
  22. 22. 22 Foot at risk - 1Foot at risk - 1 • Our job – look after “NDF at risk”Our job – look after “NDF at risk” • A: Preventive measuresA: Preventive measures • Treatment - rapid and intensiveTreatment - rapid and intensive • RestRest • Off loadOff load • AntibioticsAntibiotics • Foot wearFoot wear • Patient educationPatient education
  23. 23. 23 Foot at Risk - 2Foot at Risk - 2 • B. Metabolic controlB. Metabolic control – HyperglycemiaHyperglycemia – HypertensionHypertension – HyperlipidaemiaHyperlipidaemia – Cessation of smokingCessation of smoking • C. Deformity managementC. Deformity management • D. Callus managementD. Callus management • E. Debridement and dry skin and fissureE. Debridement and dry skin and fissure
  24. 24. 24 Foot at risk - 3Foot at risk - 3 • F. Mechanical controlF. Mechanical control – Off load, Off load, Off loadOff load, Off load, Off load • by rest, crutches, walkers, protective shoes,by rest, crutches, walkers, protective shoes, heel protective pad, decrease plantarheel protective pad, decrease plantar pressure by removal calluspressure by removal callus • G. The importance of callus removal in NFUG. The importance of callus removal in NFU • decrease plantar pressuredecrease plantar pressure • shows full dimension of the ulcershows full dimension of the ulcer • deep swab possibledeep swab possible • drainage of exudate, removal of dead tissuedrainage of exudate, removal of dead tissue • H. Infection controlH. Infection control • I. Educational controlI. Educational control
  25. 25. 25 Acute Chronic Assess Assess vascular Status Vascular status A/B index > 0.7 Peripheral pulses A/B Index Assess Extent weak / not palpable > 0.7 of Infection A/B index < 0.5 Localised wound Deeper Inf. No Charcot Charcot Foot Colour Doppler CT Scan Conservative Treatment Dedridement on Rule out MRI Complete rest Angiography Anatomical Principles Osteomyelitis Nuclear plaster cast scan antibiotics Revascularization Revacularization Dressing Contact Surgery not feasible off loading cast CT. off loading Strict & POP cast Surgery Angioplasty Gene Therapy Higher Amputation Rehab Reconstruction off loading Till stage of Footwear dressing reformation Ischaemic pain No ischaemic pain Prolonged Gradual antibiotic cover Mobilisation Strict off loading Gradual Foot wear Auto amputation Mobilisation restricted Activity Foot wear SURGICAL TREATMENT OF Assess Neuropathy Rule out Charcot Foot WOUND DIABETIC FOOT By Dr. Arun Bal
  26. 26. 26 Preventing Neuropathic FootPreventing Neuropathic Foot Ulcers - 1Ulcers - 1 • Regular inspection of foot - annuallyRegular inspection of foot - annually • Identification of high risk feet – 3 mo / 6moIdentification of high risk feet – 3 mo / 6mo • Careful choice of foot wearCareful choice of foot wear • Regular chiropodyRegular chiropody • Intense educationIntense education
  27. 27. 27 Preventing neuropathic footPreventing neuropathic foot ulcers - 2ulcers - 2 • ““As little as one hour’s educationAs little as one hour’s education provided by the podiatrist resulted in 70%provided by the podiatrist resulted in 70% reduction in amputations over thereduction in amputations over the following 2 years . as compared with afollowing 2 years . as compared with a control group who did not receive thecontrol group who did not receive the advice”advice”  Malone IM et al 1989Malone IM et al 1989
  28. 28. 28 Management involvesManagement involves • Bed restBed rest • Pressure offloadingPressure offloading • Reduction of edemaReduction of edema • Glycemic controlGlycemic control • Most important step is the early detectionMost important step is the early detection • of a high risk foot by simple tests / fewof a high risk foot by simple tests / few • quantitative testsquantitative tests

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