Whether the stage 5 foot is neuropathic or neuroischaemic it should always be regarded as a clinical emergency which should be seen by the diabetic foot service without delay and preferably the same day that it is noticed.

Fig. 6.12 Dry necrosis which began when the2ndtoewas pricked to obtain a blood sample. The 2nd toe has already autoamputated.

Patients with necrosis should not be treated solely in the community, by individual health-care practitioners: this is unfair both to patients and health-care professionals. However, most patients will need follow-up wound care from the community nursing team as well as the hospital.

It is important for health-care practitioners and patients to be aware that necrosis does not automatically progress to major amputation. Necrosis can often be successfully treated. However, each class of foot requires a different approach to the management of necrosis.

In the neuropathic foot, wet gangrene due to infection can be treated with intravenous antibiotics and surgery.

In the neuroischaemic foot, this approach may also be used, but when the foot is very ischaemic, revascularization should be performed if feasible. If vascular intervention is not possible, surgery should be avoided if possible, and intravenous antibiotics may be used to convert wet necrosis to dry necrosis.

Dry necrosis in the neuroischaemic foot can be successfully managed with revascularization of the foot and amputation. If vascular intervention is impossible, some cases of dry necrosis will do well and autoamputate with conservative care alone.

Patients should be admitted immediately for urgent investigations and multidisciplinary management. It is important to achieve:

• Wound control

• Microbiological control

• Vascular control

• Mechanical control

• Metabolic control

• Educational control.

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