APPROACH TO CHILD WITH

CYANOSIS

Dr.Hafsa sohail
 OBJECTIVES

o Types of cyanosis
o Causes of cyanosis
o Management
o Investigations & Treatment
 INTRODUCTION

o Cyanosis is derived from the colour ‘cyan’ which comes

from ‘kyanous’, the Greek word for blue.
o DEFINITION:
o It is Bluish discoloration of skin and mucous membrane
caused by increase concentration of reduced hemoglobin
> 5g/dl
o So, it is not less pronounced if the child is anemic.
 TYPES OF CYANOSIS

o Peripheral cyanosis
o Central cyanosis
o Differential cyanosis
 PERIPHERAL CYANOSIS

(Blueness of hands & feet)

Normal systemic arterial
oxygen saturation.
The increased extraction of
oxygen results from sluggish
movement of blood through
the capillary circulation
 PERIPHERAL CYANOSIS

o SITES: o CAUSES:
o Tip of nose o Vasoconstriction (exposure to
o Ear lobules cold)
o Outer aspect of lips, chin, cheek o Polycythemia
o Tips and nailbeds of fingers, toes, o Low cardiac output
palms and soles
o Tongue is spared
 CENTRAL CYANOSIS

Pathologic condition caused

by reduced arterial oxygen
saturation
Due to oxygenation defect in
lungs or admixture of venous
and arterial blood
Involves highly vascularized
tissues, through which blood
flow is brisk
 CENTRAL CYANOSIS

o Cardiac output typically is o SITES:

normal, and patients have o Tongue (margins & undersurface)
warm extremities.
o Inner aspect of lips
o It is evident when O2
saturation falls below 90% o Mucous membranes of gums,
From 90_95% (desaturated) soft palate, cheeks
o o
 DIFFERENTIAL CYANOSIS

o Asymmetrical bluish discoloration between the upper and

lower extremities.

o Seen in Patent Ductus Arteriosus with pulmonary

hypertension.

o The deoxygenated blood in the pulmonary artery goes

through the PDA.
 CAUSES OF CENTRAL CYANOSIS

Respiratory Disorders : CNS Disorders :

o Upper airway obstruction o ICH
o Respiratory distress o Birth asphyxia
syndrome (RDS) o Seizures
o Meconium aspiration(MAS)
o Pneumonia (sepsis)
o Pulmonary hypoplasia
 CAUSES OF CENTRAL CYANOSIS

o CARDIAC DISORDERS:
o Cyanotic congenital heart diseases (right to left shunt)
o 5Ts
o Tetralogy of Fallot (TOF)
o Transposition of great vessels (TGA)
o Total anomalous pulmonary venous return
o Truncus arteriosus
o Tricuspid atresia
o Persistent cyanosis in otherwise well infant is nearly always a
sign of CHD
 o Others :
o Polycythemia
o Methemoglobinemia
o Metabolic diseases
o Infection: Septicemia

CAUSES OF PERIPHERAL CYANOSIS

o Peripheral arterial disease

o Vasoconstriction
o Venous obstruction
 MANAGEMENT

DOs:
1. Complete maternal and newborn history
2. Perform a full physical examination
3. Investigations
 HISTORY

ASK:
• Sites at which it was noticed? Onset? Duration? Frequency?
• Cyanotic spells, squatting in older infants
• Exacerbation and relieving: feeding, crying, coughing
• Associated Symptoms: chest pain, palpitations, syncope, SOB
• Ask about pregnancy history and prenatal testing
• Ask about perinatal history and birth defects
• Ask about family history of congenital heart disease.
 PERINATAL HISTORY

o Drug intake:
o Causing neonatal depression
o Lithium- Ebstein anomaly
o Phenytoin- PS and AS
o Maternal diabetes- TGA, ventricular septal defect (VSD), and
hypertrophic cardiomyopathy
o Connective tissue disorder- Heart blocks • Congenital
intrauterine infections
o Antenatal fetal echocardiography
 ONSET OF CYANOSIS IN CARDIAC LESIONS

o Depends on
o Nature and severity of the anatomic defect
o In utero effects of the structural lesion
o Alterations in cardiovascular physiology secondary to the
effects of transitional circulation like closure of ductus
arteriosus and the fall in pulmonary vascular resistance
 HISTORY- RISK FACTORS

o Pneumonia/Sepsis o MAS
o TTN o Pneumothorax
o Polycythemia o Hyaline membrane disease-
 PHYSICAL EXAMINATION

o Vital signs:
o Hypothermia or hyperthermia-infection
o Tachycardia-hypovolemia
o Weak pulses- Hypoplastic left heart syndrome or
hypovolemia
o Pulses or blood pressures stronger in the upper than in
the lower extremities-coarctation of the aorta.
 PHYSICAL EXAMINATION

o Congenital Heart Disease:

o Respirations often are unlabored unless there is
pulmonary congestion or complicated by the development
of heart failure or acidosis, which will affect the
respiratory pattern.
o CVS:
o Presence or absence of a heart murmur is of little
assistance. Loud S2 suggests pulmonary or systemic
hypertension or malposition of the aorta.
 PHYSICAL EXAMINATION

o Inspiratory stridor-
o upper airway obstruction
o Chest-
o Asymmetric chest movement combined with severe
distress-
o Alarming sign for tension pneumothorax, diaphragmatic
hernia
o Transillumination of the chest-
o Pneumothorax on an emergent basis
 PHYSICAL EXAMINATION

o P/A-
o Scaphoid abdomen-
o Congenital diaphragmatic hernia
o Hepatosplenomegaly-
o Congestive heart failure, maternal diabetes, or congenital
infection.
 PHYSICAL EXAMINATION

o Central nervous depression-

o Causes shallow, irregular respirations and periods of
apnea.
o Affected infants typically appear hypotonic and lethargic.
 INVESTIGATIONS

o Pulse Oximetry: (normal O2 sat. ≥ 95%)

o ABGs:
o PaCO2: may indicate pulmonary or CNS disorders
o pH: sepsis, circulatory shock, severe hypoxemia
o Hyperoxia test (is it due to cardiac or pulmonary
cause?)
o Placing the infant in 100% oxygen for 10 minutes. If he
remains cyanotic after this period, the cyanosis is said to
be secondary to cyanotic heart disease (SaO2 not reach
the normal value)
• CBC:
or WBC: sepsis
Hematocrit > 65% : polycythemia
• Methemoglobinemia: SaO2, normal PaO2, Chocolate brown
blood, HB-M
• Sepsis screening
• ECG: Dx for Tricuspid atresia (Lt axis deviation only is seen)
• Echo: Dx for CHD
• Chest X-Ray
 CHEST X-RAY

o Aberrancy of the cardiothymic silhouette-

o Suggest the presence of structural heart disease, and
o Abnormalities of the lung fields may be helpful in
distinguishing a primary pulmonary problem such as
meconium aspiration
 CHEST X-RAY

o Pulmonary vascular markings-

o Decreased in CHD with obstructed pulmonary blood
flow such as tetralogy of Fallot, severe pulmonary stenosis
or atresia, and tricuspid atresia.
o Increased in admixture lesions like transposition of the
great arteries, total anomalous pulmonary venous
connection, and truncus arteriosus.
 TOTAL ANOMALOUS
PULMONARY VENOUS RETURN

Snowman Appearance
TRANSPOSITION OF GREAT
ARTERIES

Egg on a string Appearance

TETRALOGY OF FALLOT

Boot shaped Appearance

 TREATMENT

o Warming of the affected area: In peripheral cyanosis

o Oxygenation and adequate ventilation
o (PaO2 normalizes completely during artificial ventilation in
infant with CNS disorder)
o IV Fluids: Children who have difficulty in feeding due to
cyanosis need fluids to be administered
o If sepsis is suspected or another specific cause is not
identified, start on broad spectrum antibiotics then obtain
a full septic screening
o Drugs:
o Prostaglandin E1 For ductal dependent CHD IV
o Infusion of PGE1 at a dose of (0.05- to maintain patency
0.1mcg/kg/min)
o S/E- hypoventilation, apnea, edema and low grade fever
o Surgery
CONCLUSION
 QUESTIONS

o 1.What are the different sites for Central Cyanosis

and Peripheral Cyanosis?

o 2.Name the four components of Tetralogy of Fallot.

Of these four, which one most determines the
severity of the cyanosis?
 ANSWERS

o 1.Central- tongue, inner aspect of the lips, mucous membranes

of gums Peripheral- outer aspect of lips, tips of nose, ear
lobules, tips of fingers

o 2.Ventricular septal defect (VSD), overriding aorta, pulmonic

stenosis, right ventricular hypertrophy. The severity of the
pulmonic stenosis is the most important factor in determining
the degree of cyanosis
THANKYOU