Information sourced from BMJ:
BMJ 2016;354:i4584
[Free full-text BMJ article PDF]
Endgames
Spot Diagnosis
Cold feet
Andrew McDonald Johnston, Joseph Singleton
Correspondence to: A McD Johnston amcdjohnston@gmail.com
A man in his 70s presented to hospital with delirium and hypothermia. He had a history of alcohol misuse and had not been seen for three days. He was found in the bathtub with wet clothing. The outside temperature on the days before admission was 10°C. He had loss of sensation in his feet with areas of ulceration and necrosis. What is the diagnosis?
Answer
Non-freezing immersion injury—“trench foot”
Discussion
The patient was hypothermic, with a temperature of 32.3°C. He was bradycardic and hypotensive, requiring intravenous vasopressors. He was treated for community acquired pneumonia and alcohol withdrawal. His loss of sensation with areas of ulceration and necrosis are all features of “trench foot” or non-freezing immersion injury. Trench foot occurs after prolonged exposure to cold and wet conditions in soldiers or patients with physical or mental health problems. During rewarming the feet are extremely painful, and some patients develop long term pain and impairment of vascular function. Management includes adequate analgesia for neuropathic pain and treating any associated illnesses. The patient was given warmed intravenous fluid and a forced air warming blanket, with care being taken to keep his feet outside of the warm air flow to avoid further damage due to overheating poorly perfused tissue. Careful nursing care by specialist tissue viability nurses improved his altered sensation and resolved any pain by day 10. The patient was discharged seven weeks later and was able to walk 80 m. Two months later he was abstinent of alcohol and had recovered, apart from some healing foot ulcers.
Patient consent: Obtained.
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Publicado en Actividades Académicas, Actualización medica, Casos Clínicos, Casos Interesantes, Curso de Educación Continua |