A 72-year-old man is brought to the emergency department by his daughter after she found him confused and febrile at home. Since the patient's wife died 6 months ago, he has insisted on continuing to live independently; however, he has taken worse care of his health, including refusing doctor's visits. Medical history includes type 2 diabetes, chronic kidney disease, and peripheral artery disease. Temperature is 38.3 C (101 F). Blood pressure is 98/54 mm Hg and pulse is 104/min. The patient is lethargic but opens his eyes when his name is called. He is not oriented to place, time, or situation. Both lower extremities are without palpable dorsalis pedis, posterior tibial, or popliteal pulses. The left foot is shown in the image below. In addition to obtaining blood cultures and administering antibiotics, which of the following is the best next step in management of this patient?

Question

A 72-year-old man is brought to the emergency department by his daughter after she found him confused and febrile at home.  Since the patient's wife died 6 months ago, he has insisted on continuing to live independently; however, he has taken worse care of his health, including refusing doctor's visits.  Medical history includes type 2 diabetes, chronic kidney disease, and peripheral artery disease.  Temperature is 38.3 C (101 F).  Blood pressure is 98/54 mm Hg and pulse is 104/min.  The patient is lethargic but opens his eyes when his name is called.  He is not oriented to place, time, or situation.  Both lower extremities are without palpable dorsalis pedis, posterior tibial, or popliteal pulses.  The left foot is shown in the image below.  In addition to obtaining blood cultures and administering antibiotics, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient with peripheral artery disease (PAD) leading to gangrene of his distal left foot now has signs of systemic infection (eg, fever, confusion, lethargy). In this setting of infected gangrene, amputation of the foot should be performed promptly to remove the infectious source and prevent overwhelming sepsis. Despite its morbidity, lower extremity amputation may be necessary and even lifesaving to remove ischemic, infected, and/or necrotic tissue. Indications for lower extremity amputation include: Critical limb ischemia without the ability, either anatomically or due to comorbidity contraindications, to perform revascularization Unsalvageable lower extremity soft tissue (eg, trauma, gangrene, frostbite) Life-threatening infection (eg, infected gangrene, necrotizing soft-tissue infection) In this patient, urgent amputation without soft-tissue closure (ie, guillotine amputation) will likely be performed; this removes the obvious necrotic tissue and encourages further drainage to avoid trapping any ascending infection. Following continued antibiotics and dressing changes, if the patient clinically improves and the wound appears clean and viable, secondary stump soft-tissue closure can occur. (Choice B) Hyperbaric oxygen (HBO) therapy can augment oxygen delivery to ischemic tissues and improve wound healing. Although HBO may eventually be indicated (eg, delayed healing due to PAD), this patient's gangrenous tissue causing systemic infection demands that amputation be performed first. (Choice C) Some patients with advanced PAD may benefit from a revascularization procedure to improve distal lower extremity perfusion, if appropriate distal vessel targets are available. However, in this patient with infected gangrene, revascularization would not reverse established tissue necrosis and may require foreign body (eg, synthetic graft) placement, which would further increase infection risk (eg, infected graft). Amputation must be performed to prevent overwhelming sepsis. (Choices D and E) Sharp local wound debridement and/or whirlpool therapy (ie, immersion in a turbulent warm water bath) may be performed to remove superficial necrotic tissue (eg, eschar) or thick exudate in preparation for dressing changes. However, given the severity of this patient's PAD (eg, absent distal pulses in bilateral lower extremities) and the extent of gangrene seen in the image (ie, the distal foot and 4 toes), amputation is indicated. Educational objective: Indications for lower extremity amputation include nonrevascularizable limb ischemia, unsalvageable soft-tissue damage, and life-threatening infection (eg, infected gangrene).

A 72-Year-Old Man Is Brought to the Emergency Department by His