.approach to cyanosis

1. INTRODUCTION TO
MEDICINE
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
2017

2. Doctors specializing in internal medicine are called internists,
Internal Medicine
The 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 internists
or physicians

3. 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

4. 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

5. Internal Medicine , Management ,
sequence of roles
1-DIAGNOSIS
2-TREATMENT
3-PREVENTION

6. 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..)

7. Approach to patient = Management of patient

8. 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.

9. • 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.

10. 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.

11. CYANOSIS
/

12. Cyanosis is a blue or purple discoloration
of the skin
by :
and mucous membranes caused
5 g/dL
methemoglobin
_

14. 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.
/_ --~

15. • 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
/_ --~

16. 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
<90% and usually indicates underlying cardiac or
pulmonary disease.
• Cardiac causes include pulmonary edema and
congenital heart disease.
Congenital defects associated with central cyanosis
include Eisenmenger's syndrome and Fallot's tetralogy.
/_ --~

17. • 2-peripheral(pink lips, cool peripheries)
Peripheral cyanosis may result when cutaneous
vasoconstriction
(acrocyanosis).
Not affect tongue
It is physiological during cold exposure.
• It occurs in heart failure, when reduced cardiac output
produces reflex cutaneous vasoconstriction,
and venous obstruction, e.g. deep vein
thrombosis. .
slows the blood flow in the limbs
--~
produces refle
vascular disease
/_

18. Cyanosis types
Skin & mUC'QUS • Penpheral exposed skin•
• Caused by decreased • Caused by
• Exposed
Clubbing
areas warm
may be
• Exposed areas cold,
massage/warmin
g
help
s
·
'-._---
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

19. •Cold
• M@t
•Shunt
cardiac output
Perilpheral cyanosis Central eya osis
•Polycythemia
•Altitude
•Obst ructto n
•Lung disease
•lVF and shock
sulfhemoglobinemia
•Decreased
Mnemonic: h'COLD PALMS"

20. • Cardiogenic shock with
pulmonary edema, there
may be a mixture of both
central and peripheral
cyanosis.
/_ --~

21. Approach to Cyanosis
ry
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,
obstruction.
pulmonary embolus,
2. Symptomatic? Asymptomatic patients may have methemoglobinemia
(congenital
(prescribed
Intermittent
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.

22. )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
problems?
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?

23. 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

24. e oximetry estimates oxygen saturation but does not measure it
directly.
necessary
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.

25. An electrocardiogram may demonstrate acute myocardial infarction,
ventriculararrhythmia, or pericardial process. P pulmonale, right
hypertrophy, and right axis shift suggest chronic pulmonary disease.
4. An echocardiogram can help diagnose both diastolic and systolic heart
failure, as well as visualize wall motion abnormalities that may be present
in acute or prior myocardial infarction. Evidence of pulmonary
hypertension can also be seen on echocardiogram
5. Chest computed tomography (CT) may identify pulmonary emboli
cardiac
and
andprovide more information than chest x-ray in a variety of
pulmonary d
biseases.
~~~~)ocardlOgram
,~~~ Computer
reCO«ls
$01100 WQII'C ~
,nd ol$plnys
picWfe
1
P8tlen1.oes on
be<!on lienside
SooographCf
movesIr8lSdIJ«(
on palAn!', cIloo$l
H•• r1 Electrode palcl10s
aUoched10cnesc
(1Of EKCl)

26. THANK YOU