Cyanosis & nail abnormalities

cyanosis

1. Cyanosis By: Dr. Amrinder Singh Junior Resident General Medicine

2. Cyanosis Definition : bluish discolouration of the skin & mucous membrane due to presence of increased amount of deoxyhaemoglobin in blood. Absolute concentration of deoxyhaemoglobin : > 4gm/dl Cyanosis is a grave sign & needs immediate evaluation of underlying cause & its intervention

3. Mechanism of cyanosis Alveolar hypoventilation Diffusion impairment Ventilation-perfusion mismatch Right-to-left shunting at the intracardiac, great vessel, or intrapulmonary level Hemoglobinopathy (including methemoglobinemia, sulphaemoglobinemia ) that limits oxygen transport

4. Etiology of cyanosis

5. Types of Cyanosis

6. Peripheral cyanosis Arterial blood is normally saturated i.e. PaO2 is normal SPO2 is normal Excessive extraction of oxygen from normally saturated arterial blood due to Reduced cardiac output Peripheral vasoconstriction Decrease blood flow rate in extremities

7. Sites to be examined Tip of nose Ear lobules Outer aspect of lips,chin & cheeks Tip of fingers & toes Nail-bed of finger & toes Palms & soles Note: Tongue remains unaffected in peripheral cyanosis

8. Causes of peripheral cyanosis Exposure to cold air or water Congestive cardiac failure Frost bite Raynauds phenomenon Shock Venous obstruction/ arterial obstruction Hyperviscocity syndrome Cryoglobulinemia Mitral stenosis i.e. seen in mitral facies septicaemia

9. Central cyanosis Decrease in oxygen saturation i.e. low PaO2 Due to decrease or imperfect oxygenation of blood in lungs or mixing of arterial & venous blood SPO2 usually < 85%

10. Sites to be examined Tongue ( margins as well as undersurface ) Inner aspect of lips Mucous membrane of gums , palate, cheeks. Lower palpebral conjunctiva Notes sites mentioned in pheriphal cyanosis In dark skin person examination of oral muscosa & tongue will help

11. Causes of central cyanosis Cyanotic congential heart disease Acute pulmonary oedema i.e. most common cardiac cause Eisenmenger syndrome Acute severe asthma COPD Lober pneumonia Fibrosing alveolitis Acute laryngeal odema Acute pulmonary thromboembolism Pulmonary arteriovenous fistula

12. Enterogenous cyanosis Also known as pigment cyanosis Due to excessive sulphaemoglobin (>0.5 gm/dl) or methaemoglobin (1.5gm/dl) in blood Causes : Hereditary haemoglobin M disease Poisoning with Aniline dyes Drugs includes nitrate & nitrites i.e. NTG , amyl nitrite, sodium nitroproside , Dapsone Carboxyhaemoglobinemia

13. Diagnosis of enterogenous cyanosis H/O of ingestion of sweets H/O of drug intake On examination skin & mucous membrane is blue but patient is not breatheless

14. Differential Cyanosis Hands red ( i.e less blue) and feet blue commonlyu seen with PDA with reversal of shunt. Reverse of differential cyanosis in which hands blue & feet red or normal Seen in coarctation of aorta with transposition of great vessels

15. Differential diagnosis of bluish colouration of body Cyanosis Carbon monoxide poisoning Argyria Osteogenesis imperfecta Drugs like amiodrone

16. Mixed cyanosis Central + peripheral cyanosis causes include Congestive heart failure with Left heart failure Acute myocardial infarction wityh acute LVF Polycythemia rare cause

17. Invesgations for cyanosis Hematocrit or hemoglobin Sepsis screening Blood glucose concentration Arterial blood gases (Pao2, Paco2, pH) Blood cultures Chest X rays Electrocardiography Echocardiography, cardiac catheterisation angiocardiography Hemoglobin electrophoresis- Hb M

18. Treatment of cyanosis It is a symptom of an underlying condition rather than being a disease in itself. Treatment of cyanosis thus focus on the Treatment of underlying disease rather than the symptom alone. Symptomatic treatment of cyanosis - Warming of the affected areas Oxygenation as a treatment for cyanosis Intravenous fluids

19. Revision Features Central cyanosis Peripheral cyanosis Sites Tongue & oral cavity mainly Hands , toes , ear lobules, tip of nose Skin on touch Warm due to increase blood flow cold Dyspnoea Usually present No respiratory distress Pulse Normal or high volume Low volume O2 application test i.e for 10 mins Cyanosis improve No response Clubbing & polycythemia present absent Application of warmth & cold No response Warmth cyanosis decrease Cold cyanosis inctrease

20. Thank you