Top Banner

Click here to load reader

L 1.approach to cyanosis

Jan 22, 2018




    Dr.Bilal Natiq Nuaman,MD

    C.A.B.M. , F.I.B.M.S. , D.I.M. , M.B.Ch.B.

    Lecturer in Al-Iraqia Medical College


  • Doctors specializing in internal medicine are called internists,

    Internal MedicineThe branch of medicine that deals with the diagnosis and nonsurgical treatment of diseases affecting adults within its scope .

    The medical specialty dealing with the prevention, diagnosis, and treatment of adult diseases.

    Doctors specializing in internal medicine are called internistsor physicians

  • Scope of Subspecialties of Internal Medicine

    Cardiology, dealing with disorders of the heart and blood vessels

    Endocrinology, dealing with disorders of the endocrine system and its specific secretions called hormones

    Gastroenterology, concerned with the field of digestive diseases

    Hematology, concerned with blood, the blood-forming organs and its disorders.

    Infectious Diseases, concerned with disease caused by a biological agent such as by a virus, bacterium or parasite

  • Nephrology, dealing with the study of the function and diseases of the kidney

    Pulmonology, dealing with diseases of the lungs and the respiratory tract

    Rheumatology, devoted to the diagnosis and therapy of rheumatic diseases.

    Neurology dealing with diseases of nervous system

    Medical Oncology, dealing with the chemotherapeutic(chemical) treatment of cancer

    Poisoning and Critical Care

  • Internal Medicine , Management , sequence of roles




  • Medical Diagnosis

    Sequence of Diagnosis

    1-History taking from patient (record patient symptoms)

    2-Examination of the patient (looking for physical signs )

    3-Investigations (done in lab. ,etc..)

  • Approach to patient = Management of patient

  • Symptom vs sign

    A symptom(complaint) is subjective feeling from the patient point of view.

    A symptom is what the patient experiences about the disease.

    Symptoms can only be experienced, they are not able to be observed or measured objectively.

    Pain is a symptom. I do not know you are having pain unless you tell me. Nausea is also a symptom, as are: chills, numbness, fatigue, vertigo, malaise, itching, stomach cramps, burning on urination, etc.

  • A sign is an objective physical manifestation of disease.

    It is an objective finding, something one can observe and measure.

    A rapid pulse, a high temperature, a low blood pressure, an open wound, bruising, etc. are all signs.

    Signs give a more definite indication of the presence of a particular disease to the physician.

    So in the simplest form, signs are observations of the doctor and symptoms are the experiences of the patient.

  • Patients commonly have complaints (symptoms). These symptoms may or may not be accompanied by abnormalities on examination (signs) or on laboratory

    testing. Conversely, asymptomatic patients may have signs or laboratory abnormalities, and laboratory abnormalities can occur in the absence of symptoms or signs.



  • Cyanosis is a blue or purple discolorationof the skinby :

    and mucous membranes caused

    5 g/dL



  • Approximately 5 g/dL of deoxygenated hemoglobin in the capillaries generates the dark blue color appreciated clinically as cyanosis. For this reason, patients who are anemic may be hypoxemic without showing any cyanosis.

    Conversely, the higher the total hemoglobin content, the greater the tendency toward cyanosis.

    /_ --~

  • Methemoglobin results from the presence of iron in the ferric (oxidized) form instead of the usual ferrous form. This results in a decreased availability of oxygen to the tissues.

    When 15-20% of hemoglobin is methemoglobin , Cyanosis will result , though patients may be relatively asymptomatic

    /_ --~

  • Types of cyanosis

    1-central(blue and warm) This is seen at the lips and tongue .

    It corresponds to an arterial oxygen saturation (SpO) of

  • 2-peripheral(pink lips, cool peripheries)Peripheral cyanosis may result when cutaneousvasoconstriction(acrocyanosis).

    Not affect tongue

    It is physiological during cold exposure.

    It occurs in heart failure, when reduced cardiac outputproduces reflex cutaneous vasoconstriction,

    and venous obstruction, e.g. deep veinthrombosis. .

    slows the blood flow in the limbs


    produces refle

    vascular disease


  • Cyanosis types

    Skin & mUC'QUS Penpheral exposed skin

    Caused by decreased Caused by



    areas warm

    may be

    Exposed areas cold,



    '-._---Oxygen Cyanosismay disappear

    in ri ht to left shunt

    in pulmonary case (Except Disappears

    Central Peripheral

    membranes only

    arterial oxygen sat. or vasoconstriction or

    abnormal hemoqlobin decreased blood flow

    present No clubbinq

  • Cold

    [email protected]

    Shuntcardiac output

    Perilpheral cyanosis Central eya osis



    Obst ructto n

    Lung disease

    lVF and shock



    Mnemonic: h'COLD PALMS"

    mailto:[email protected]

  • Cardiogenic shock with pulmonary edema, there may be a mixture of both central and peripheral cyanosis.

    /_ --~

  • Approach to Cyanosis


    Onset? Is the cyanosis of recent onset or has it been present since birth? A1.

    history of cyanosis since birth and "squatting" in childhood suggest

    congenital heart disease. Chronic cyanosis caused by methemoglobinemia

    can be congenital or acquired. Other causes of chronic cyanosis include

    chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, and

    pulmonary atrioventricular fistula. Acute and subacute cyanosis can be

    caused by acute myocardial

    pneumonia, or upper airway

    infarction, pneumothorax,


    pulmonary embolus,

    2. Symptomatic? Asymptomatic patients may have methemoglobinemia

    (congeni tal



    or drug induced) or sulfhemoglobinemia. Exposures to drugs

    and!or illicit) or environmental factors should be reviewed.

    cyanosis, skin color changes, and pain with cold exposure

    suggest Raynaud's phenomenon. Symptomatic patients, especially with

    chest pain and respiratory distress, are more likely to have a cardiac or

    pulmonary cause of cyanosis.

  • )Y

    3. Risk Factors? Does the patient have known risk factors for cardiac or

    4. Family History or Past Medical History? Is there a family history of


    pulmonary disease, including smoking, hyperlipidemia, asthma, drug abuse

    (especially methamphetamines), severe obesity (sleep apnea),

    neuromuscular disease, or autoimmune disease? Does the patient have

    chest pain or intermittent cyanosis with exercise, suggesting angina? Chest

    pain can be present with acute pulmonary emboli or pneumothorax. Is there

    a cough and fever suggesting pneumonia? Has the patient had any

    occupational or environmental exposures that might cause pulmonary


    abnormal hemoglobin or pulmonary disease? Has the patient suffered an

    episode of hypotension that could produce adult respiratory distress

    syndrome (ARDS), such as sepsis or heart failure?

  • B. Physical Examination

    1. Initial assessment. Vital signs: tachycardia suggests cardiac arrhythmia,

    shock, volume depletion, anemia, or fever. An increased or decreased

    respiratory rate and use of accessory musculature suggest hypoxia.

    Hypotension can signal vascular collapse.

    2. Additional physical examination. Stridor suggests upper airway

    obstruction. Examine the pharynx for evidence of obstruction. If epiglottitis

    or the presence of a foreign body is suspected, be prepared to intubate the

    patient. Check the neck for evidence of jugular venous distention.

    Auscultate the chest for rales suggestive of pulmonary edema, wheezing,

    and rhonchi consistent with reactive airway disease or absence of breath

    sounds, suggestive of pneumonia or pneumothorax. Auscultate the heart for

    murmurs, arrhythmias, and abnormal heart sounds. Feel the pulses in the

    extremities to assess for arterial embolus or venous thrombosis, especially,.................,_..,....-- .........

    if cyanosis is localized to one extremity. Examine the abdomen for

    evidence of intra-abdominal catastrophe or aneurysm. Examine the nails

    for evidence of clubbing, which is suggestive of chronic pulmonary

  • e oximetry estimates oxygen saturation but does not measure it



    Direct measurements using arterial blood gases (ABGs) are

    to assess a patient with cyanosis. Patients with abnormal

    hemoglobin types have a normal Pao , but decreased hemoglobin O2

    saturation A low Pao , is caused by respiratory or cardiac problems in

    most circumstances.

    2. A chest radiograph helps assess heart size

    suggest pneumonia, ARDS, or pulmonary

    and lung parenchyma. Infiltrates

    edema. Exclude pneumothorax.

    Look for evidence of interstitial lung disease. Pleural effusion can

    represent infection, malignancy, or pulmonary edema.

  • An electrocardiogram may demonstrate a

Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.