Internal and external treatment of diabetic foot
Pyrexia gangrene is a disease characterized by ulceration of the ends of the lower extremities, which can lead to necrosis and amputation of the affected limb in severe cases. It is one of the most important complications of thirst disorders and is equivalent to the “diabetic foot” in Western medicine.
I. Diagnosis
This disease is diagnosed with reference to the “Diabetes Prevention and Treatment Guidelines for Chinese Medicine” issued by the Chinese Academy of Traditional Chinese Medicine in 2007.
Chinese medicine treatment
1.Internal treatment
(1) Cold and stasis blocking the ligament type
Symptoms: The affected toes (fingers) are warm and cold, pale, cold, numb, painful, aggravated by cold, unfavorable gait and intermittent limping. The tongue is dark and pale, the coating is white and greasy, the pulse is sunken and thin, and the tarsus pulse is weakened or disappears.
Treatment: Promoting blood circulation, dispersing cold and relieving pain.
Remedy: Radix Angelicae Sinensis Sibiricus with Addition and Reduction.
Composition: Radix Angelicae Sinensis 30g, Cinnamomum Cassiae 10g, Radix Paeoniae Alba 12g, Radix Rehmanniae 30g, Cornu Cervi Pantotrichum 10g, Radix Ginger 10g, Radix Sinensis 3g, Rhizoma Di Lung 15g, Rhizoma Ligustici Chuanxiong 10g, Radix Achyranthis Bidentatae 10g, Radix Codonopsis Pilosulae 5g, Centipede 1 (research and dose).
Addition and subtraction: for Yang deficiency and fear of cold, add 10g of deer horn gum, 10g of rehmannia, 3g of roasted ephedra, 6g of cinnamon (later down); for dampness, add 3g of white mustard seed and 10g of atractylodes.
Proprietary Chinese medicine: Astragalus injection 20ml added to 5% glucose injection or 0.9% sodium chloride injection 250ml intravenous drip once a day. This stage is mostly seen in old and weak patients with lesions, Astragalus injection has the effect of benefiting Qi and supporting Yang.
(2) Blood vessel stasis type
Symptoms: pain in the affected toe (finger), increased pain and swelling, weakness, the skin color of the affected limb turns from pale to dark red, or even purple and dark. Toe (finger) nail growth is poor or purple, tongue is dull red or with petechiae, pulse is stringent or astringent, tarsal pulse is thin and astringent or disappears.
Treatment: Invigorate blood circulation, remove blood stasis, warm the meridians and open the channels.
Formula: Blood Mansions and Blood Stasis Soup with Addition
Composition: Radix Achyranthes bidentata 10g, Radix et Rhizoma saffron 10g, Radix Angelicae Sinensis 10g, Radix Aconiti 10g, Radix papaya 10g, Radix et Rhizoma Pinelliae 30g, Radix Boswelliae 10g, Radix Myrrh 10g, Radix Cinnamomi 10g, Radix Szechuan pepper 10g, Radix et Rhizoma Dioscorea 15g, Radix Paeoniae 10g, Radix Glycyrrhiza Uralensis 5g.
Addition and subtraction: for Qi deficiency causing blood stasis, add Astragalus membranaceus 30g; for Qi depression causing blood stasis, add Radix et Rhizoma Polygonati 10g, Radix Aromaticus 10g; for Yang deficiency causing blood stasis, add Radix et Rhizoma Polygonati 6g, Radix et Rhizoma Sinensis 3g; for phlegm and blood stasis interconnection, add Radix et Rhizoma White Mustard 3g.
Chinese patent medicine: Compound Blood Vine Tongluo capsule (in-hospital preparation) 3 capsules, taken orally three times a day. Chuanxiongzin injection 80mg added to 5% glucose injection or 0.9% sodium chloride injection 250ml intravenously once a day.
(3) Heat poisoning and Yin injury type
Symptoms: The affected toe (finger) is mostly dry gangrene, infection, redness, swelling, heat, pain, pus, odor, high fever, irritability, thirst, and even delirium, constipation and urination. Dry skin, hair loss, thickened and deformed toenails, muscle atrophy, red tongue, yellow fur, and fine pulse.
Treatment: Nourish Yin and clear heat, detoxify and invigorate blood.
Remedy: Gu Bu Tang plus or minus.
Composition: Radix et Rhizoma 15g, Radix et Rhizoma Ginseng 10g, Radix et Rhizoma Macrocephala 15g, Radix et Rhizoma Yam 10g, Radix et Rhizoma Cornus 10g, Radix et Rhizoma Ginseng 15g, Rhizoma Chuanxiong 10g, Radix et Rhizoma Yinhua 30g, Radix et Rhizoma Dioscorea 10g, Radix et Rhizoma Peach 10g, Radix et Rhizoma Salviae Miltiorrhizae 10g, Radix et Rhizoma Yujin 10g.
Addition and subtraction: Astragalus 30g and Dendrobium 20g can be added for deficiency of both Qi and Yin.
Chinese medicine: compound Danshen injection 20ml added to 5% glucose injection or 0.9% sodium chloride injection 250ml intravenous drip once a day.
(4) Heat poisoning type
Symptoms: severe pain in the affected toe, light day and heavy night, like cool and afraid of heat, local skin purple, swollen, gradually become purple-black, infiltration spread, ulcerated and rotten, flesh color of the wound surface is obscure, or even five toes penetrate each other, spread to the back of the foot or accompanied by fever, red tongue, yellow greasy coating, pulse string count.
Treatment: Clearing heat and cooling the blood, detoxifying and regenerating the muscles.
Formula: Si Miao Yong An Tang with reduction
Composition: Radix Rehmanniae 15g, Rhizoma Ligustici Chuanxiong 10g, Rhizoma Shanjia 5g, Radix Paeoniae Alba 10g, Radix Panax Ginseng 15g, Fructus Flos Lactucidum 30g, Radix et Rhizoma Gingivalis 30g, Radix Myrrh 6g, Rhizoma Dioscorea 15g, Rhizoma Huang Lian 6g, Radix Glycyrrhiza Uralensis 5g.
Addition and subtraction: for heat, add 30g of forsythia, 10g of cypress, 10g of scutellaria; for dampness, add 10g of fangji, 15g of poria, 10g of zedoary, 10g of chrysanthemum; for blood stasis, add 20g of salvia.
Chinese medicine: often with Qing Kai Ling injection 20ml add 5% glucose injection or 0.9% sodium chloride injection 250ml intravenous drip, once a day, with the effect of clearing heat and detoxification.
This type of evidence is mostly seen in the acute stage of demyelination, mostly accompanied by generalized fever and chills.
(5) Qi and blood deficiency type
Symptoms: Shortness of breath and weakness, yellowish complexion, muscle atrophy of the affected limb, dry and flaky skin, dry and thick toenails; the sore surface does not heal for a long time after the necrotic tissue falls off, the flesh buds are dark red, or light red and not fresh, the tongue is light, the pulse is thin and weak.
Treatment: Benefit qi and nourish blood, and support the sore to produce muscle.
Remedy: Ten whole tonic soup with reduction
Composition: Astragalus membranaceus 30g, Radix Codonopsis pilosulae 15g, Radix Angelicae Sinensis 10g, Rhizoma Chuanxiong 10g, Radix Paeoniae Alba 15g, Rhizoma Atractylodis Macrocephalae 10g, Poria Cocos 15g, Angelicae Dahuricae 10g, Radix Angelicae Sinensis 15g, Radix Glycyrrhiza Uralensis 6g.
Addition and subtraction: for severe blood deficiency, add 20g of Radix Polygoni Multiflori, 20g of Radix Rehmanniae; for Yang deficiency and fear of cold, add 6g of Cinnamon, 3g of Hesperidin, 10g of Cinnamomum.
Chinese medicine: Astragalus injection 20ml added to 5% glucose injection or 0.9% sodium chloride injection 250ml intravenous drip once a day. It has the effect of benefiting qi, supporting yang and generating muscle.
2.External treatment method
(1) Clearing method.
① incisional debridement and drainage: suitable for local abscess, sinus tract with small mouth cavity, cellulitis, mostly wet gangrene, necrotic tissue reaching below the fascia muscle, obvious local swelling, serious infection, stable vital signs, difficult to control blood sugar and good general condition.
② nibble clearing method: suitable for traumatic surface purple or pale, foreseeable one-time clearing difficult to bear; more dry gangrene or mixed gangrene, vital signs are not stable, and the general condition is poor.
(2) Topical lotions.
① San Huang lotion: suitable for the formation of sinus tract trauma pus out more, local tissue redness, swelling and heat pain, involving bone, sinus tract does not heal for a long time.
Composition: Rhubarb, Huanglian, Huangbai, Lianxiao.
Usage: repeatedly flush the sinus tract with the medicinal solution extracted by syringe 3-5 times a day.
②Warm foot external washing formula: for numbness and coldness of the feet, fear of cold, aggravated by cold.
Composition: Gui Zhi, Wei Ling Xian, Chuan Xiong, Chuan Wu, Cao Wu, Hosin, Chuan Pepper, Angelica.
Usage: The temperature of the medicinal solution is at 35-40℃, fumigate the feet for 20-30 minutes.
③ Detoxifying lotion: for limbs with more necrotic tissues, traumatic exudation, local tissue redness, swelling and heat pain.
Composition: Bitter ginseng, flea sap, yellow cypress, yellow lily, inoceramus, zelenium, orchid, ditin.
Usage: The temperature of the medicinal solution is at 35-40℃, fumigate the foot for 20-30 minutes.
(3) External application of medicine.
①Redness or pus formation before ulceration is Yang evidence, can be applied externally with Jinhuang paste.
②After the pus is not much, the wound surface is red, swollen and painful, you can use comfrey oil ointment to apply externally.
③When the wound surface is slightly red, swollen and painful, with little pus and no new flesh, external application of Qing gangrene ointment can be used.
④With no redness, no swelling, no pus, light-colored buds and no new flesh, you can use Astragalus myogenic ointment for external application.
⑤Growing muscle powder applied externally: applicable to those whose necrotic tissues have been removed and whose wounds do not heal for a long time.
3.Other therapies.
(1) Femoral artery injection therapy: Applicable to severe narrowing of arterial vessels, with or without ulcers. Use compound salvia injection 10ml, or pulsatilla injection 20ml or Chuanxiongzin injection 40mg or scopolamine injection 10 mg; urokinase 300,000 units added to 0.9% sodium chloride injection 20ml, alternate femoral artery injection, once a day, 10-15 times for a course of treatment.
Contraindications: those with septic infection around the injected acupuncture point and those with bleeding tendency.
(2) acupuncture point injection therapy: this method can improve the blood flow and nerve function of the affected limb and promote wound healing, commonly used drugs dissolved in sterile injection water 1.5ml, pancreatic kininogenase needle 20 units, three Yinjiao acupuncture point injection once a day. Danshen, methylcobalamin, vitamin B1, Chuanxiongzin and other injections can also be used to take the acupuncture points of foot Sanli, Blood Sea, Yanglingquan, etc.
Contraindications: septic infection around the injection point; serious local ischemia at the injection site with a tendency to necrosis.
(3) Acupuncture method.
①Take acupuncture points according to the meridian: first identify the main meridian of the ulcerated area, and take the corresponding meridian points to unblock the qi and blood of the meridian. For example, if the disease is in the foot Yangming Stomach meridian, take the points such as Li Tui, Nei Ting, Ji Gu, Chong Yang, Feng Long and Foot San Li. If the disease is in the foot Taiyin Spleen meridian, take Yin Bai, Du Du, Tai Bai, Shang Qiu, Yin Ling Quan, etc.; if the disease is in the foot Shao Yin Kidney meridian, take Chung Quan, Ran Gu, Tai Xi, Yin Gu, etc.; if the disease is in the foot Sun Bladder meridian, take Tong Bone, Kun Lun, Wei Zhong, etc.; if the disease is in the foot Shao Yang Bile meridian, take Di Wu Hui, Man Xi, Qiu Hui, Yang Ling Quan, etc.; if the disease is in the foot Convulsive Yin Liver meridian, take Zhong Feng, Qu Quan, Tai Chong, Xing Inter, etc.
②Discriminatory acupuncture points: if blood vessels are more stagnant, add Blood Sea and Diaphragm Yu; if tendon and bone injuries are more severe, add Hanging Bell and Yangling Spring; if edema is more severe, add Water and Water Channel.
③Tonic and diarrhea method: follow the principle of tonic for deficiency and diarrhea for reality.
Note: Operate according to the contraindications of acupuncture.
(4) Intermittent gradient pressure therapy instrument: improve the circulation of blood and lymphatic fluid in the limbs through air pressure, improve the lack of oxygen in limb tissues, repair nerve function, and relieve symptoms such as numbness, pain, chills and intermittent claudication in the hands and feet.
Contraindication: It is contraindicated for those with severe cardiac and renal insufficiency and trauma infection.
4.Regulation and care
(1) Prevent bruising, stabbing and crushing of the affected limb, and wear shoes of appropriate size.
(2) Pay attention to whether the affected toe is ulcerated or necrotic, and pay attention to its skin temperature and color change.
(3) In general, avoid eating fatty, sweet and thick food, eat a light diet, stop smoking and limit alcohol. In addition, according to the different types of identification of the diet, such as cold and damp obstruction of the ligament appropriate food to warm the meridians and open the ligament products, Qi and blood deficiency should be appropriate food to benefit the Qi and nourish the blood products, damp and heat toxicity of the appropriate food to clear heat and damp products.
(4) Maintain a relaxed mood and build up confidence.
Third, the efficacy of evaluation
1, cure: gangrene wound completely healed has formed a scab or scar.
2, improved: gangrene local secretions significantly reduced, most of the gangrenous necrotic tissue off or part of the granulation of new wounds significantly reduced.
3, invalid: gangrene trauma without significant reduction, no significant reduction in secretions, no significant local changes in gangrene or even deterioration.