Hot red foot

A hot, red foot can be a manifestation of a number of conditions, including:

In critical ischaemia a number of changes occur that can confuse the clinical picture. Rather than a cold, painful foot you may find a hot, swollen foot because:

  • The ischaemic foot is maximally vasodilated
  • Perfusion increases when the foot is dependent and so the limb may have been "Hung low" for some time (typically at night)
  • Immobility causes venous stasis
  • Ischaemia can predispose to local sepsis

Inappropriate antibiotic therapy for critical ischaemia can delay diagnosis and treatment and is a common source of litigation in primary care

The key discriminator is the presence or absence of a normal arterial circulation on examination

Assessment

History and Examination

History
  • Diabetes
  • Previous vascular symptoms (intermittent claudication)
  • Vascular risk factors (smoking, hypertension, hypercholesterolaemia)
  • Pain? History of neuropathy?
  • Response to previous antibiotics (if given)
Examination
  • Presence of tissue loss or necrosis
  • Temperature
  • Compare with the other side
  • Pulse assessment and Doppler signal examination

Differential Diagnoses

The key differentials are between:

  • The foot that is hot and red due to critical ischaemia
  • The foot that is red and hot due to infection in a diabetic
  • Acute Charcot foot
  • Other causes - e.g. gout.

Red Flags

High index of suspicion in diabetics: contained pus in a diabetic foot is an emergency

Suspicion of severe ischaemia

Investigations

If the arterial circulation is normal:

  • Patient's temperature
  • Inflammatory markers
  • Plain foot x-ray if sepsis or Charcot considered likely (particularly in diabetics)

Management

Referral

Referral Criteria

Referral Instructions

Emergency referral to diabetic foot clinic
  • Monday – Friday telephone 01392 402204
  • Out of hours contact medical triage via switchboard 01392 411611
Urgent referral to vascular specialist
  • Immediate via ED or on call vascular specialist via switchboard
  • For discussion with a consultant ring switchboard and ask for vascular surgeon of the week

Supporting Information

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG.

Publication date: May 2015

 

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