Grand Rounds Recap 1.24.18

MORBIDITY AND MORTALITY CONFERENCE WITH DR. LAUREN TITONE

Case 1:  Sepsis Vs. DKA

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• Diabetic Ketoacidosis (DKA)
  • Definition:  Requires all 3 elements
    • Hyperglycemia 
    • Ketosis
    • Acidosis
  • Symptoms
    • 50-80% Present with nausea and vomiting
    • 30% Present with abdominal pain
    • Body temperature usually low (Low metabolic state)
      • If the patient is febrile, this is an extra concern for infectious etiology
    • Assessing severity
      • Associated with more severe presentation
        • pH
        • Bicarbonate
        • Mental Status
      • Glucose level does not correlate with severity
  • Diagnosis
    • Assess for acidosis (Blood gas)
    • Assess for elevated glucose (Fingerstick or renal panel)
    • Assess for ketones
      • Methods
        • Urine
          • Detects Acetoacetate and Acetone
            • ~25% of ketones produced in DKA
          • Less sensitive than blood because does not include beta-hydroxybuterate
          • If negative, may require follow up blood test if high clinical suspicion for DKA
        • Blood
          • Detects beta-hydroxybuterate
            • ~75% of ketones produced in DKA
          • More sensitive than urine
          • If negative, consider other cause of symptoms apart from DKA
  • Common Precipitants of DKA
    • New onset diabetes  (Usually type-I)
    • Insulin non-compliance / change in regimen  (Usually type-I)
    • Infection
    • CV disease
    • Many others (CVA, hyperthyroidism, pancreatitis, pregnancy, etc)
    • Infection as a Precipitant for DKA
      • Several studies looking at indications of infection as source of DKA
      • Common findings correlating to infection as trigger for DKA
        • Elevated lactic acid
        • Bandemia
        • Female sex
        • AMS
        • Fever in the last week
        • Complete clearance of ketones from urine in 24 hours

Case 2:  Pericarditis

• Background
  • 80-90% of cases are idiopathic
  • Men account for 2/3 of hospitalized cases
  • 1/3 of cases associated with myocarditis
  • LV dysfunction and arrhythmias are uncommon
  • Low mortality rate
  • Usually self-limited
  • May recur 2-3 times in lifetime
• Diagnosis
  • Requires 2 out of 4 criteria
    • Chest pain
      • Abrupt onset is not unusual
      • Sharp and pleuritic
      • Usually positional component
        • Classically described as being relieved by sitting forward
        • NOT always the case
      • Radiation to trapezius ridge (pathognomonic)
      • Premonitory viral symptoms
    • Friction rub
      • Classically triphasic
      • High pitched/squeaky
      • Highly specific
      • Best heard over left sternal border
    • Pericardial effusion
      • Must be larger than trivial effusion
      • Present in 2/3 of cases
      • Large effusion present in 3%
    • Characteristic EKG changes
      • Concave ST segment elevation in multiple leads
      • Diffuse PR Depression with PR elevation in aVR (Though not specific)
      • Things to consider
        • Ischemia
          • ST elevations in vascular distributions, any reciprocal ST depressions
        • Benign early repolarization
          • Ratio of ST elevation to T wave height
          • If <.25, then likely early repolarization
          • Also fishhook at J point suggestive of early repolarization
  • Additional diagnostics
    • CBC/BMP/LFT
    • Troponin (Can help rule out myocarditis, ischemia, etc)
    • CRP
      • Will be elevated in pericarditis
      • Can help if diagnosis is uncertain
      • Also useful in terms of trending over time for recovery (normalizes in 1 week)
    • Echo
      • Assess for effusion
    • Chest X-Ray (Rule out other causes of chest pain)
    • Cardiac MRI or CT if unclear
• Management
  • Criteria for discharge
    • Clinical picture consistent with viral infection
      • Temp < 101.5 F
      • WBC < 13,000
      • No anemia
    • Immunocompetent
    • No history of trauma
    • No troponin elevation / evidence of perimyocarditis
    • No large effusion
    • No anticoagulant use (aspirin OK)
    • Good follow up
  • Treatment
    • NSAIDs:  
      • Ibuprofen 600-800mg q6-8 hours OR ASA 2-4 grams daily
    • Colchicine
      • Weight based
      • >70Kg = .5mg BID
      • <70Kg = .5mg daily
    • Steroids
      • Not routinely recommended
      • Used if patient unable to tolerate NSAIDs

Case 3:  Pulmonary Embolism (PE) => Cardiac Arrest

• Tissue Plasminogen Activator (tPA) administration in the setting of PE Arrest
  • Do not use routinely in cardiac arrest
    • TROICA trial - "Thrombolysis During Resuscitation for Out-of-Hospital Cardiac Arrest"
    • Found routine use of pre-hospital intra-arrest tPA did not improve outcomes (Mortality)
  • Use should be based on clinical suspicion for PE
    • Signs and symptoms of PE on history
    • Pre-arrest diagnostics
      • Pre-arrest cardiac ultrasound with right heart strain
        • Note:  Intra-arrest cardiac ultrasound is not reliable in determining RV dilation
        • Cardiac dysfunction is common following arrest and may appear similar to RV dilation
  • Earlier administration during arrest secondary to PE correlated with better outcomes
    • Decreased time to ROSC
    • Improved mortality
  • Administration
    • Lack of unified recommendations and lack of consistency in trial design
    • Several societies have published recommendations
      • British Thoracic Society:  50mg Bolus
      • European Society of Cardiology:  100mg bolus OR .6mg/kg infusion over 15 minutes
      • American Heart Association:  100mg over 20 minutes
    • General Recommendation
      • Anywhere between 50-100mg probably appropriate
      • Anecdotal recommendations
        • 50mg bolus, then additional 50mg drip over 1 hour 

Case 4:  Influenza

• "High Risk" Patients
  • Age 
    • <2 and >65 at high risk
    • <6 months and >85yo at extreme risk
  • Immunosuppressed  (HIV/AIDS, Chemo, Medical immunosuppression, Malignancy)
    • HIV/AIDS:  Still considered immunosuppressed even if CD4 is > 200
  • Pregnant or postpartum women  (Increased admission rates and severe outcomes)
  • Extremely obese patients (Increased mortality)
  • Nursing home/long term care facility residents
  • Patients with medical comorbidities
    • Asthma
    • Chronic lung disease
    • Heart disease
    • Kidney disease
    • Liver disease
    • Metabolic disorders
    • Neuro/developmental disorders
• Testing
  • Indications:
    • Fever + Respiratory symptoms + One of the following
      • "High risk"  (See Above)
      • Immunocompromised
      • Children
      • Recently hospitalized patients
    • Sepsis of unknown source
• Treatment (Oseltamivir)
  • Indications:
    • Test positive for flu
    • PLUS
      • "High risk"  (See Above)
      • Hospitalized patients
      • Any patient with severe, progressive, or complicated illness
  • Timing
    • Shown to decrease symptom duration in healthy volunteers if given in first 48 hours
    • However
      • Benefit seen in "High risk" patients with administration as late as 5 days
• Disposition
  • Reassuring factors
    • Fever controlled / normalizes
      • Fever that does not normalize/come down with medication may represent underlying bacterial infection
      • Morbidity for superimposed or concomitant bacterial infection is significantly higher
    • Respiratory function stable
      • Patient not tachypneic/hypoxic
      • Chest X-Ray reassuring
        • May be worth repeating after hydration if dehydrated
    • Repeat assessment/vitals is key

Case 5:  Perforated Viscous

• Risk factors
  • Instrumentation / surgery
  • Trauma
  • Ingestion of foreign body
  • Violent wretching
  • IBD
  • Appendicitis
  • PUD
  • Diverticular disease
  • CV Disease
  • Neoplasm
  • Connective tissue disorder
  • Medications
    • NSAIDs
      • Decrease mucosal lining
      • Implicated in colonic diverticuli
    • DMARDs
      • Lower intestinal perforation
    • Glucocorticoids
      • Slows intestines' ability to repair itself
        • Colonic perforation more likely
        • Greatest risk is in first 3 weeks of therapy
      • Suppress inflammatory response (Delayed detection)
        • Detection delay
        • Delayed onset of treatment
      • Mortality increased by 77% if taking more than 20mg prednisone
      • OR of perforation compared to NSAIDs, opiates, calcium channel blockers, placebo = 28.28
• Presentation
  • Classic
    • Sudden onset of pain usually focal
    • Often expands to diffuse peritonitis
    • Pain onset may vary depending on location of perforation
      • Cervical esophagus:  Neck pain, odynophagia, dysphagia, tenderness
      • Upper abdomen:  Diaphragm irritation (referred shoulder pain)
      • Retroperitoneum / lesser sac:  Back pain (may be subtle)
    • However
      • May have latent period of no pain following initial perforation
      • Especially common w/ immunosuppressive agents (Steroids)

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CLINICAL KNOWLEDGE:  PEDIATRIC BLOODY STOOLS WITH DR. SHAN MODI

Pediatric Bloody Stools

• Causes:
  • Best divided by age
    • Neonate - Infant (0-1 year old)
      • Swallowed maternal blood
      • Anal fissures
      • Necrotizing enterocolitis
      • Duplication of bowel
      • Hirschprungs
    • Infant (1-2 years old)
      • Milk protein allergy
      • Anal fissures
      • Infectious colitis
      • Meckel's diverticulum
      • Intussussception
    • Pre-school age (2-5 years old)
      • Henoch Shonlein Purpura (HSP)
      • Anal fissures
      • Infectious colitis
      • Meckel's diverticulum
      • Hemolytic uremic syndrome (HUS)
    • School age (6-12 years old)
      • HSP
      • Anal fissures
      • Infectious colitis
      • Meckel's
      • hemorrhoids
• Important history
  • Age
  • Diet
    • Many foods can cause stool to be red / look bloody
    • Reaction/allergy to foods can cause GI bleeding
  • Exposures
  • Sick contacts
  • Abdominal pain
  • Fevers
  • Behavioral change/AMS
• Case based discussion
  • Case 1:  4 year old fully vaccinated female with 3 days of fever, mild abdominal discomfort, watery diarrhea that has recently become bloody.  Exam demonstrates sick appearing child with mild abdominal tenderness and bloody fecal matter in the rectal vault.  Labs demonstrate a mild leukocytosis.
    • Diagnosis:  Infectious colitis
      • Salmonellosis
        • Usually in children < 5 years old
        • Rare bloody stools
      • Shigellosis
        • Usually in children 1-4 years old
        • Watery stools, that progress to bloody stools
        • Complications:
          • Megacolon
          • Seizures
        • Management
          • Usually self limited
          • Antibiotics if:
            • Signs of bacteremia
              • Fever
              • Leukocytosis
              • Hypothermia
              • Lethargy
              • Culture proven shigellosis
      • Campylobacter
        • 0-8 years old
        • Abrupt onset with pain and diarrhea
        • Complications:
          • Guillain Barre
      • E.Coli
      • Yersenia
        • Fever and RLQ pain
        • Can mimic appendicitis
  • Case 2:  2 year old female with up to date vaccinations with episodic severe abdominal pain, vomiting x 4, and episodic bloody stools.  She is in mild distress on exam, and generally uncomfortable.  She endorses RUQ tenderness.  
    • Diagnosis:  Intussussception
      • Ultrasound of abdomen
        • "Lawn mower" pattern over abdomen with abdominal probe
        • Findings
          • "Target sign" in cross section
          • "Stacks of pancakes" in longitudinal
      • Management
        • Air enema for distal intussussception
        • Conservative management also possible with observation for resolution
        • Likely surgery required for persistent small bowel intussussception
  • Case 3:  5 year old female with 3 days of abdominal pain, diarrhea and recent diagnosis of gastroenteritis who presents with continued pain, rash on her legs, and pain in her joints.
    • Diagnosis:  Henoch Shonlein Purpura
      • Background
        • Microangiopathic hemolytic anemia
        • Usually occurs following infection (Shiga Toxin E. Coli)
      • Presentation
        • Abdominal pain
        • Joint pain common
        • GI bleeding possible
        • AKI
        • Hemolysis
      • Evaluation
        • CBC:  Assess for anemia
        • BMP:  Assess for kidney injury
        • Urinalysis:  Assess for proteinuria
      • Management
        • Tylenol and ibuprofen for pain
        • Can give steroids if significant pain
          • Do not affect disease course
        • PCP follow up regularly to monitor kidney function
        • Admit if:
          • Can't tolerate PO
          • Severe abdominal pain or GI bleeding
          • AMS
          • Joint pain preventing ambulation
          • AKI or signs of kidney injury
  • Case 4:  2 day old male born at 39 weeks with initial APGAR score of 7 improved to 9 in 5 minutes with only brief hospital stay who presents to the ED with bloody streaks in his bowel movements.  He is well appearing, tolerating feeds well, making regular wet diapers, and has a benign exam.
    • Diagnosis:  Swallowed maternal blood
      • Etiology not quite clear
      • Swallowed likely during birth/c-section
      • May also occur in delayed fashion if nipple irritation during breast feeding

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R4 CLINICAL SOAP BOX:  HEALTHCARE COST AND WASTE WITH DR. CLAIRE O'BRIEN

Healthcare cost

• 17.8% of nations GDP goes towards healthcare
• 3.2 Trillion dollars
• US spending is significantly greater than other developed countries
• Outcomes are not necessarily greater

Healthcare waste

• 25-30% of health expenditure is wasted
• 765 Billion dollars
• 6 major sources of waste
  • Unnecessary services  (210 Billion annually)
    • Of Medicare patients, 25-42% of patients had an episode of "Low Value Care"
    • Examples
      • Overuse of radiographic studies
      • Excessive antibiotic use for viral infections
      • Non-indicated cancer screening
      • Frequent/unnecessary hospitalization for low risk chest pain
      • Why do we do this?
        • Discomfort with diagnostic uncertainty
        • Defensive medicine
        • Patient pressure / demand
        • Time pressure
    • Strategies to avoid overspending
      • Avoid head CT in low risk trauma (Use criteria)
      • Include hospice early
      • Avoid IV fluids in patients who can take PO
      • Avoid admission for low risk complaints
        • Low risk syncope
        • Low risk chest pain
  • Inefficient services
    • Medical supply waste
      • UCSF Study examined their own performance in single center study
        • Examined costs over 1 year in NSGY department
          • $968 dollars wasted per surgical case
          • Equates to $242,968 monthly
          • 3 million dollars wasted annually in single department
        • Explored impact on physician education
          • Reduced cost
          • Outcomes either same or improved as well
  • Price too high
  • Fraud
  • Administrative cost
  • Missed prevention 

Summary

• Waste accounts for 25-30% of all healthcare spending
• Physicians contribute to waste
• Educating physicians can reduce cost
• Evidence based practice also shown to reduce cost

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REFRACTORY SHOCK WITH DR. NATALIE KREITZER

Background

• 750,000 admits a year for septic shock
• Number increases each year as the patient population ages
• Hospital mortality decreased over the last 10 years thanks to:
  • Surviving sepsis campaign
  • Order sets
  • Increased compliance with care bundles has reduced mortality
• Historic context
  • Early Goal Directed Therapy (Dr. Rivers) 2001
    • Introduced several key concepts in sepsis management
      • Fluid resuscitation
      • Early antibiotic administration
      • Looking at set end-points / markers for monitoring
    • Many elements questioned / shown to be erroneous
      • PROCESS trial
      • PROMISE trial
    • However, this trial changed the culture with regards to managing sepsis and septic shock
    • Overall culture change may be why there was no difference between EGDT and other treatments
  • Recent changes / directions in sepsis management
    • Less blood administration
    • Less fluid
    • Less insulin
    • Less oxygen
      • Danger of hyperoxia becoming known
      • Less PEEP for ARDS
    • Less sedation
      • Seroquel
      • Precedex
    • No CVP monitoring

Monitoring / End Points

• Regional perfusion / Clinical exam
  • Mental status
    • Correlates with significantly higher mortality in septic shock
    • RR 2.19 for mortality if AMS present
  • Cap refill time
    • Correlated with age, sex, and vascular disease
    • Correlates with lactic acid, UOP, and high qSOFA score
  • Skin mottling
    • Specific but not sensitive
    • Scoring systems exist
  • Temperature gradient
    • Forearm to fingertip gradient > 4 C can signify shock state
• Hemodynamic changes
  • MAP Goals
    • Great endpoint
    • Ideal MAP can vary between patients
    • NEJM recently published RCT comparing patients in septic shock randomized to high MAP vs. low MAP in patients with HTN
      • No mortality benefit in high MAP group
      • However, Low MAP group with hx of HTN required more dialysis
    • Caveat
      • Often requires invasive monitoring
  • SCVO2 and SVO2
    • Can help determine oxygen extraction ratio
    • Higher extraction ratio suggests "Thirsty Tissue"
    • May suggest tissue not getting adequate perfusion
  • Other dynamic measurements
    • SV Variation
    • Passive leg raise
    • POCUS
    • Nicom
• Metabolic derangement
  • Lactate normalization
    • Traditionally thought to represent tissue perfusion
    • Found to be affected by both flow dependent AND flow dependent states
      • Ex. Epinephrine increases lactic acid production
      • Increased glycolysis => Increased pyruvate => Overwhelms Krebs cycle =>  Excess pyruvate converted to lactate

Management of Septic Shock

• Fluids
  • Problems with "Filling the tank" model
    • Does not address R heart or large vein function
      • Large veins also have some elasticity
      • May need to improve this / decrease compliance in addition to "filling tank" to improve pre-load
    • Does not address kidney function/resuscitation
  • How much is enough
    • Little data exists
      • FEAST Trial
        • Performed in Africa in pediatric population
        • Mortality was higher in kids who received boluses regularly for hypotension
      • Marik et al 2013
        • Retrospective review of Precision database
        • Evaluated 24,000 patients in septic shock
        • 5 Liters or more on day 1 predicted greater mortality
    • Summary
      • Current model of roughly 30cc/Kilo may be OK
      • Some patients may benefit from less fluids and earlier pressors
• Renal resuscitation
  • Kidneys are extremely sensitive to hypoperfusion
  • Excessive fluid resuscitation may lead to extended shock
    • Fluids may damage endothelial glycocalyx
    • Excess chloride vasoconstricts afferent arteriole in the kidney
• Peripheral pressors
  • Trial looking at safety of peripheral pressors came up with following recommendations regarding their use
    • Ideally in vein > 4mm diameter
    • Avoid access in hand or wrist
    • 18-20 gauge needle
• Antibiotics
  • Early administration is known to be beneficial
  • Important to consider timely redosing in boarding patients in the ED
    • Delayed second dose has been shown to increase mortality
  • Combination of antibiotics is important
    • Vancomycin and pip-taz
      • Large meta-analysis demonstrated OR of 2.68 for developing AKI compared to Vanc and Cefepime
      • Add Flagyl if concerned about losing anaerobic coverage
• Vasopressors and Inotropes
  • Norepinephrine
    • Recommended 1st line
    • Shown to be superior to dopamine 
      • RR of death is .91 compared to dopamine
    • Shown to be equivocal in terms of MAP with epi
      • However, epi had increased metabolic derangements
  • Epinephrine
    • Hits all adrenergic receptors (pressor + inotrope)
    • May be beneficial as 1st line in patients with low sympathetic tone
    • Inotropic effect of epi may be beneficial in low kinetic heart
  • Vasopressin
    • Acts on V1 and V2 to increase SVR and increase blood volume
    • 4 RCTs looking at vasopressin use in addition to other pressors
      • All showed improved renal function
      • All showed decreased need for other pressors
      • Very safe
    • Probably most helpful in milder forms of shock
    • Main benefit is kidney protection in pressor use/shock
• Steroids
  • Previously debated with landmark trials like ANANE and CORTICUS
  • ADRENAL Trial just recently published
    • 3,800 patients enrolled
    • Compared hydrocortisone 200mg daily vs. placebo in septic shock
    • All other treatment the same
    • Results
      • No mortality difference at 90 days between the two groups
      • More adverse events in hydrocortisone group
  • Interpretation
    • Likely not beneficial in most patients
    • May still have role in patients who are steroid dependent at baseline

New innovations in sepsis

• IVIG
• Calcium
  • Thought to be "Natural pressor"
  • No evidence that supra-normal calcium will be of benefit
  • Studies examining drugs that increase calcium sensitivity have shown no benefit
  • May benefit to normalize calcium in hypocalcemic patients
• Methylene blue
  • MOA:  Inhibits guanylate cyclase
  • Shown to be beneficial in post operative vasoplegia
  • Contraindicated in G6PD Deficiency
  • Systematic review looking at efficacy in sepsis
    • Included 2 studies
    • Total N was still less than 40
    • Resulted in decreased pressor use and increased MAP
• Bicarb or THAM
  • No great evidence examining their use
  • Maybe worth a shot in refractory shock?
• Esmolol
  • Paper by Morelli in JAMA examined effect of HR control with esmolol in shock
  • Included 154 patients (Not randomized)
  • Demonstrated decreased mortality
  • However, control group had 80% mortality suggesting other factors at work
• PLEX
  • Thought is that it removes toxins precipitating shock
  • No great evidence
  • 4 separate trials exist
    • All use vastly different definitions of septic shock
    • Though they have varying results
• Hydrocortisone, vitamin C, and thiamine
  • One clinical study (Retrospective study)
  • All in 1 ICU
  • No randomization
  • All septic shock patients received treatment
  • Compared to 7 month period before protocol where patients did not receive treatment
  • Attempted to retrospectively adjust
    • Age
    • Weight
    • Sex
    • etc.
  • Results
    • 47 patients in each group
    • Mortality 8.5% in treatment group compared to 40.4% in control group
    • No sepsis related deaths reported in treatment group
  • Limitations
    • All at 1 center
    • Small sample size
    • Non-concurrent subjects
    • Likely needs further investigation
• Angiotensin II
  • Early trials comparing angiotensin II administration vs. placebo demonstrated 10% MAPs in angiotensin II group
  • No studies examining impact on mortality
  • Further study required

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CONSULTANT OF THE MONTH:  PODIATRY WITH DR. ANTHONY BLANCHARD

Foot Wounds and Osteomyelitis

Background

• Historically known as an "Abscess of the medulla" or "Boyle of bone marrow"
• Treatment prior to antibiotics was always surgical
• Common causes
  • Hematogenous spread
  • Direct inoculation
• Usually occurs in phases
  • Acute
    • Often has local and systemic symptoms
    • Harder to detect on radiographs
    • More amenable to antibiotics and debridement
  • Subacute
    • Bone marrow destruction
    • Usually evident on radiographs
  • Chronic
    • Management of chronic osteo varies depending on location and patient
    • Debate risk of chronic infection vs. loss of limb/surgery

How to Assess a Wound

• Exam
  • See if wound probes to bone
    • Exposed bone increases likelihood/risk of osteomyelitis and bony involvement
    • Moderate predictive value of osteo (22-66%)
    • High negative predictive value (If wound doesn't probe to bone, osteo much less likely)
• Labs
  • WBC
  • ESR/CRP More valuable over blood cell count
  • Culture
• Imaging
  • X-Ray
    • May not show signs of acute osteomyelitis
    • May only detect sub-acute or chronic osteomyelitis changes
  • MRI is preferred diagnostic method.  Often done as outpatient

Wound Staging/Classification Systems

• Lew and Waldvogel
  • Considers acuity of osteo and mechanism of infection
  • Acuity
    • Acute
    • Sub Acute
    • Chronic
  • Mechanism of Spread
    • Hematogenous
    • Spread from local wound
    • Direct
• Cierny Mader System
  • Classifies by anatomy, as well as overall health of host
  • Anatomy
    • edullary
    • Superficial
    • Localized
    • Diffuse
  • ost classes
    • therwise healthy
    • Local, sytemic compromise
    • Morbidity of treatment is worse than disease
• Wound, Ischmia, Foot Infection (WIFI) Classification system
  • Wound:  Graded 0-3
    • 0:  No tissue loss
    • 1:  Minimal tissue loss
    • 2:  Moderate tissue loss
    • 3:  Extensive tissue loss
  • Ischemia:  Graded 0-3
    • 0:  No ischemia ABI > .8
    • 1:  Mild ischemia  ABI .6-.79
    • 2:  Moderate ischemia  ABI .4-.59
    • 3:  Severe ischemia  ABI < .39
  • Foot infection:  Graded 0-3
    • Grade 0:  No infection
    • Grade 1:  Superficial infection, localized cellulitis < 2cm
    • Grade 2:  Moderate infection, erythema > 2cm w/ or without abscess that extends to joint or bone
    • Grade 3:  Severe infection, local infection and SIRS

Common Causes of Foot Wounds

• Vasculopathy
  • Poor blood flow leads to nutrient deprivation
  • History
    • Pain/claudication at rest
  • Clinical signs
    • Cool, thin, or stressed skin
    • Decreased cap refill
    • Hyperesthesis
  • Wound
    • Usually dry, red, well demarcated
    • Skin borders receding slowly
  • Recommendations
    • ABIs and advanced imaging as outpatient
    • Take photos for chart
    • Close follow up with vascular or podiatry
    • Mild dry gangrene still OK for outpatient
    • ADMIT for WIFI > 2-1-1
• Neuropathy (Diabetic foot ulcer)
  • Develops due to sensory and motor nerve deprivation
  • Clinical signs
    • Atrophic skin changes
    • Hyperkeratotic lesions
    • Accentuated digital contractures
    • Loss of range of motion of ankle
  • Wound
    • Usually hyperkeratotic rim
    • Moderate to high drainage
  • Recommendations
    • RED FLAGS:  Consult podiatry
      • Swelling and cellulitis our of proportion to wound
      • Remote bullae or evidence of sinus tract
      • Pain despite being insensate previously around wound
    • Discharge appropriate if
      • WIFI 2-1-1
      • Give GOOD wound care instructions
      • Give antibiotic dressing of some kind
        • Betadine
        • Dakins
        • etc. 
    • Observation appropriate f
      • Wound debridement necessary
      • Marked cellulitis