A comprehensive chapter from Toh Hong Chuen

Hyperglycemia chapter written by Toh Hong Chuen from Singapore is just uploaded to the Website!

61 - Diabetic Foot - Subcutaneous air

A 58-year-old lady presented with right foot pain for 3 days, associated with high fever, lethargy, polyuria, and polydipsia. At triage, air hunger was noted. Her vital signs were: blood pressure 82 / 46 mmHg, heart rate 131/min, respiratory rate 28/min, Temperature 38.7 and SpO2 98%. She was brought to the resuscitation room for further management.

Clinically, she was dehydrated and confused with GCS 14. Her neck was supple, and lungs were clear. Crepitus was noted on the dorsum of the right foot. Point of care blood tests showed: capillary glucose 40 mmol/L, capillary ketone 7.2 mmol/L, pH 7.22, bicarbonate 8 mmol/L, pCO2 20 mmHg, sodium 130 mmol/L, chloride 95 mmol/L, potassium 5.5 mmol/L and lactate 6.9 mmol/L.

A diagnosis of septic shock secondary to gas gangrene complicated by diabetic ketoacidosis was made. She was aggressively resuscitated with fluid and started on I.V. insulin infusion. Potassium replacement was withheld as potassium was elevated. Urinary catheterization was performed for strict input-output monitoring. Broad-spectrum antibiotics and intramuscular tetanus toxoid were given. X-ray of right foot confirmed subcutaneous air.

The patient was sent directly to the theatre and underwent extensive debridement for the gas gangrene. She had an uneventful recovery and was discharged 1 week later.

by Toh Hong Chuen from Singapore.