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51 Cards in this Set
- Front
- Back
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The unholy triad and what 3 divisions are there:
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A way to describe the pedal complications of diabetes
Neuropathy, Vasculopathy, Immunopathy |
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What are the three divisions of neuropathy with Sx:
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sensory - Sx- lack sensation, lack protective threshold, burning/numbness/tingling/ pain
Autonomic - Sx – heat intol., edema, demineralization of bones in feet, lack of sweating Motor - Sx – foot drop/loss o’ fxn, tripping/gait disturbances, deformities (hammer), equinus |
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Why is vasculopathy a part of the unholy triad and what are the Sx?
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d/t decrease in Blood Q --> increased injury and limited healing
Sx: cold feet, pale/blue toes, ↓ cap. refill, ↓ leg hair, claudication |
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Why is immunopathy a part of the unholy triad and what are the Sx?
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This is an inability to fight infection d/t increase in glucose --> hyperglycemia and altered WBC fxn
Sx: heat, red, swelling (same as always) |
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What are the four risk categories and the evualation frequency?
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0 - normal - q 12 mo
1- peripheral neuropathy - q 6 mo 2 - LOPS, deformity, +/- PAD - q 3 mo 3 - Previous ulcer/amputation - q1-3 mo |
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Wagner grading (wound classification system)
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Grade 0: no open lesion
Grade 1: superficial ulcer Grade 2: deep ulcer - tendon Grade 3: deep ulcer w/ abscess Grade 4: local gangrene Grade 5: extensive gangrene of entire foot |
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University of Texas wound classification
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Stages
Stage A: no infctn or ischemia Stage B: infctn present Stage C: ischemia present Stage D: infection & ischemia present Grading Grade 0: epithelialized wound/no wound Grade 1: superficial wound Grade 2: wound penetrates to tendon or capsule Grade 3: wound penetrates to bone |
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What contributes to a positive wound care outcomes
CDE GE |
Cleaning debridement
Disinfection Edema/exudates management Granulation Epithelialization |
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Keys to Home diabetic foot care - 6 -
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1) Inspect feet daily
2) Never walk barefoot, even indoors! 3) check water temp w/ elbows prior to entering 4) Use lotions of creams daily 5) Don’t treat wounds, corns, or calluses yourself 6) Don’t smoke; quit smoking |
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Chronic distal symmetrical symptomatic polyneuropathy
Give me: -Sensory -Motor -Autonomic c divisions and 1 associated Sx |
-Sensory
---large fibers: stabing/shooting pain ---small fibers: burning -Motor ---Proximal: atrophy ---Distal: hammertoes, HL -Autonomic ---CV: MI ---GU: ED ---GI: gastroparesis, d/c ---cutaneous: dec blood Q |
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Metabolic changes of diabetic neuropathy?
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Oxidative stress, reduction of gamma-lonolenic acid, ↑ free radicals, micronutrient deficiency
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Vascular changes of diabetic neuropathy?
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BM thickening, ↑ blood viscosity, hyper-reactive platelets
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m/c nerve compression sites?
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Common peroneal
tibial superficial peroneal deep peroneal |
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What are the two forms of Acute painful diabetic peripheral neuropathy
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Hypergylcemic neuropathy
Insulin neuritis |
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What is Hypergylcemic neuropathy?
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rapidly reversible sensory Sx in poorly controlled diabetics in episodes of elevated blood sugar
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What is Insulin neuritis?
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asymptomatic neuropathy becomes symptomatic as a result of a rapid drop in blood sugar
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Which Px exams are used to Dx peripheral neuropathy?
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vibratory sensation, light touch, proprioception, sharp/dull, protective threshold
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What is the biggest physical clue about their PAIN that helps us get to diabetic peripheral neuropathy?
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the pain is symmetric
- can also include that the pain is worse at night and disrupts sleep |
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What is the primary approach to prevent diabetic neuropathy?
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Normoglycemia (intense glucose control) or as near as possible - this decreases microvascular complications
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What are the two theraeutic categories of diabetic neuropathy?
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Symptom relief only
Disease modifying |
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What is involved in Sx relief only?
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Physical modalities (PT and topical agents)
Antidepressants (TCA, SNRI Anticonvulsants Opioids |
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What is involved in disease modifying?
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Intensive glucose management
Antioxidants/nutriceuticals (folate, Mg, Zn, BH4) Decompression |
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What are examples of a TCA?
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TRAZDONE
AMITRIPTYLINE |
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SE of TCA?
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Anti-cholinergic effects
Drowsiness Inc risk of CV death |
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How does the TCA work?
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INH NorEpi/5HT reuptake in descending pathways
also antagonizes NMDA rec (modulate hyperalgesia and allodynia) |
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What are examples of SNRIs?
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duloxetine
venlafaxine |
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SE of SNRI?
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nausea, somnolence, dizzy, constipation, dry mouth, ↓ appetite
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How does the SNRI work?
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Relieve pain by increasing the synaptic availability of 5-hydroxytryptamine and noradrenaline
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How do the anticonvulsants work?
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Bind the alpha-2-sigma subnit of Ca2+ channel, ↓ Ca2+, reduce neurotransmission
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examples of anticonvulsants?
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gabapentin
pregabalin |
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Se of anticonvulsants?
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somnolence, peripheral edema, HA, wt. gain
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What additional category of drug can be used to Tx diabetic neuropathy?
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opioids
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what are the disadvantages using opioids?
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once you start it is a life long process
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What are the opioids most commonly used?
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Tramadol
Morphine Oxycodone |
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What is evidence of an INFECTED wound?
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erythema, warmth, edema, tenderness, pain, purulence, undermining, odiferous
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How is a diabetic foot infection classified?
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Grade 1: NO signs
Grade 2 (mild): Locally infected ulcer Grade 3 (moderate): foot/limb threatening Grade 4 (severe): life threatening |
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Descirbe grade 1 DFI
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wound lacking purulence or any manifestation of infection
granular base, no deep tracts, no cellulitis, no purulence – but serous drainage is present |
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Descirbe grade 2 DFI
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≥ 2 manifestation of inflammation
Cellulitis ≥ 2cm around ulcer Infctn limited to skin or superficial subQ |
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Descirbe grade 3 DFI
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The infection is in a patient who is systemically well and metabolically stable
≥ 1 of: cellulitis beyond 2cm, lymphangitic streaking, undermining, deep tissue abscess, gangrene, involves mm/tendon/joint/bone |
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Descirbe grade 4 DFI
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life threatening- wound may “look” like grade3, but systemic toxicity will be present
Sx: Fever, chills, tachycardia, hypoTN, leukocytosis, confusion, vomiting, acidosis, severe hyperglycemia, azotemia |
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What are the Signs of a limb threatening infection?
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systemic inflamm, rapid progression, necrosis/gangrene, crepitus, soft tissue gas, bullae, new onset anesthesia, pain out of proportion, loos of neurologic fxn, limb ischemia, soft tissue loss, bony destruction, fail of infection to improve w/ tx
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What is the standard way to r/o osteomyelitis?
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bone biopsy - obtained from a location near the wound but not at the wound site exactly
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How do u Tx as an outpatient?
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Stabilize patient; in-office I&D; deep tissue culture; appropriate Abx coverage
Appropriate shoe gear/off-loading modalities; educate about appropriate wound care |
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How do u Tx as an inpatient?
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Stabilize pt; obtain labs, studies, consults; surgical I&D, deep tissue culture, post-op management & Abx
Discharge the patient as soon as possible |
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Topicals are IDSA recommended to be used for how long?
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1-2 weeks
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Examples of topicals?
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mupirocin, silver compounds, iodine compounds, gentamicin/triple Abx preps
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orals are IDSA recommended to be used for how long?
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2-4 weeks for soft tissue infection
up to 3 months for osteomyelitis |
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parenterals are IDSA recommended to be used for which types of DFI's
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Limb or life threatening DFI's.
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What are examples of mild Abx drugs?
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cephelexin, amoxicillin-clavulanate
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What are examples of moderate Abx drugs?
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ampicillin-sulbactam, ertapenem, imipenem-cilastatin, vanco, pipercillin-tazobactam
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Why bone biopsy osteomyelitis?
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gold standard
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