APPROACH TO A PATIENT WITH

CYANOSIS.

PRESENTERS
1.EYENA JACKSON
2.EGWAYU BONIFACE
3.GUMOSHABE DESIRE.
TUTOR:DR KIMULI IVAN.
OBJECTIVES:

Definition.
Types.
Causes.
Management.
History
Physical examination
Differential diagnosis
Investigation
Diagnosis
Treatment and prevention
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Definition.
• Cyanosis refers to a bluish color of the skin and mucous
membranes resulting from an increased quantity of reduced
hemoglobin, or of hemoglobin derivatives, in the small blood
vessels of those areas.
• In general, cyanosis becomes apparent when the mean capillary
concentration of reduced hemoglobin exceeds 40 g/L (4 g/dL).
• It is usually most marked in the lips, nail beds, ear lobes, and
malar eminences(cheeks).

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Types of cyanosis.
Central cyanosis.
This type is due to a circulatory or ventilatory problem that leads to poor
blood oxygenation in the lungs.
It develops when the arterial oxygen saturation drops below 85%.
Peripheral cyanosis.
This occurs due to decreased oxygenated blood flow through the peripheral
blood vessels. Probably the most common cause of peripheral cyanosis is
the normal vasoconstriction resulting from exposure to cold air or water.
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 When cardiac output is reduced, cutaneous vasoconstriction occurs as
a compensatory mechanism so that blood is diverted from the skin to
more vital areas such as the central nervous system and heart, and
cyanosis of the extremities may result, even though the arterial blood is
normally saturated.

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Causes.
Central cyanosis;

Decreased arterial oxygen saturation.

• Decreased atmospheric pressure—high altitude.
• Impaired pulmonary function.
Alveolar hypoventilation.
Uneven relationships between pulmonary ventilation and perfusion
(perfusion of hypoventilated alveoli)
Impaired oxygen diffusion.

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• Anatomic shunts.
Certain types of congenital heart disease (5Ts).
Pulmonary arteriovenous fistulas.
Multiple small intrapulmonary shunts.
• Hemoglobin with low affinity for oxygen.
Hemoglobin abnormalities.
Methemoglobinemia—hereditary, acquired
Sulfhemoglobinema— acquired
Carboxyhemoglobinemia (not true cyanosis)

Peripheral cyanosis;

• Reduced cardiac output.

• Cold exposure.
• Redistribution of blood flow from extremities.
• Arterial obstruction.
• Venous obstruction. 7
Management.
1. History.
A careful history must be obtained, particularly timing of
the onset of cyanosis. Cyanosis present since birth or infancy is
usually due to congenital heart disease.
2. Examination of the patient.
Look for physical signs and symptoms like bluish/purplish extremities
and mucous membranes.

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The presence or absence of clubbing of the digits (see below) should be
ascertained.
Peripheral cyanosis or acutely developing central cyanosis is not associated
with clubbed digits.

Clubbed fingers

Other features include breathlessness, shortness of breath, rapid and shallow

breathing.
Central and peripheral cyanosis must be differentiated. Evidence of disorders of the
respiratory or cardiovascular systems are helpful.
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• Massage or gentle warming of a cyanotic extremity will
increase peripheral blood flow and abolish peripheral but not central
cyanosis.
• Differences between central and peripheral cyanosis.
Feature Central Peripheral
Area affected Generalized Localized
Tongue Involved Not involved
Hand shake Warm Cold
Clubbing Usually present Absent
Oxygenation application Pulmonary cause improves Not improved
Warmth Not improved Improved
Mechanism Diminution of oxygen Diminution of oxygenated
saturation blood flow
Capillary refill time Less than 2seconds More than 2seconds

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3. Differential diagnosis.
Hemoglobin variants with altered oxygen affinity e.g.
methemoglobinemia

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4.Investigations

Tests include the following:

• Arterial blood gas analysis and Blood oxygen saturation by pulse oximetry.
These tests are performed to assess the amount of oxygen in the arterial blood.
• A complete blood count. This helps detect features like a low Red blood cell
count (anemia), low hemoglobin (anemia) or high RBC count (polycythemia)
etc. High counts of white blood cells are indicative of infections.
• A chest X ray to detect lung pathologies like pleural effusion etc.
• Electrocardiogram to detect abnormalities of the heart rhythm and rate.

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• Type of abnormality or defect of the heart in congenital heart defects
can be detected by imaging tests such as:
• Echocardiography,
• Transesophageal echocardiogram (TEE),
• Cardiac Doppler with Echo or Ultrasound,
• Cardiac or chest CT scan and MRI scan
• Echocardiography may be used to look inside the heart to detect the
structural defect.
• Doppler helps detect the adequate direction and amount of blood
flow across the heart and the large vessels.
• Cardiac catheterization; gives information about exactly how the
blood is being pumped through the heart.
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• Other tests for heart defects include Nuclear imaging tests and cardiac
Electrophysiologic study (EPS).

• In pneumonia and lung infections, sputum is tested for microorganisms.

Blood cultures for infection may also be prescribed.
• Ventilation-perfusion scan is recommended in patients with pulmonary
embolism. A lung angiography helps to visualize the blood vessels of the
lungs and is helpful in detection of the embolism.
• If methemoglobin or sulfhemoglobin is suspected, a Hemoglobin
spectroscopy is prescribed.
• For detection of arterial occlusion a Digital subtraction angiography may be
prescribed. Similarly a Duplex Doppler or venography is prescribed for acute
venous occlusion
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5. Treatment
• Treatment involves identifying and correcting the underlying cause in
order to restore the oxygenated blood flow to the affected parts of the
body.
Receiving proper treatment in a timely manner will improve the
outcome and limit any complications.
• There are some medications available that can help blood vessels
relax. These include:
• antidepressants
• antihypertension drugs
• erectile dysfunction drugs
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6. Prevention
Prenatal diagnosis
• Most congenital heart defects can be identified by fetal echocardiography, Ultra
sound Ultra assessment of the outflow tracts.
Antenatal corticosteroid therapy
• Antenatal corticosteroid therapy should be administered to all pregnant women at 23 to
34 weeks who are at increased risk of preterm delivery within the next seven days to
prevent or decrease the severity of neonatal RDS.
• Corticosteroids enhance maturational changes in fetal lung architecture and
biochemistry with increased synthesis and release of surfactant, resulting in improved
neonatal lung function.
Assisted ventilation techniques
• Respiratory support that prevents and reduces atelectasis should be administered to all
preterm infants who are at risk for RDS.
• Intubation and mechanical ventilation.
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THANK YOU

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