L 1.approach to cyanosis

.approach to cyanosis

1. INTRODUCTION T O MEDICINE D r .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 201 7

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 a f fecting 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 Cardiolog y , dealing with disorders of the heart and blood vessels Endocrinolog y , dealing with disorders of the endocrine system and its specific secretions called hormones Gastroenterolog y , concerned with the field of digestive diseases Hematolog y , 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. Nephrolog y , dealing with the study of the function and diseases of the kidney Pulmonolog y , dealing with diseases of the lungs and the respiratory tract Rheumatolog y , devoted to the diagnosis and therapy of rheumatic diseases. Neurology dealing with diseases of nervous system Medical Oncolog y , dealing with the chemotherapeutic (chemical) treatment of cancer Poisoning and Critical Care

5. Internal Medicine , Management , sequence of roles 1-DIAGNOSIS 2-TRE A TMENT 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 vie w . • A symptom is what the patient experiences about the disease. • Symptoms can only be experienced, they are not able to be observed or measured objectivel y . • 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. Conversel y , asymptomatic patients may have signs or laboratory abnormalities, and laboratory abnormalities can occur in the absence of symptoms or signs.

11. C Y ANOSIS /

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

13. 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. Conversel y , the higher the total hemoglobin content, the greater the tendency toward cyanosis. / _ - -~

14. • 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 / _ - -~

15. T ypes 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 tetralog y . / _ - -~

16. • 2-peripheral(pink lips, cool peripheries) Peripheral cyanosis may result when cutaneous vasoconstriction ( acrocyanosi s ). 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 / _

17. Cyanosis types S k i n & mUC ' QUS • P enphera l exp o se d skin • • C ause d by dec r eased • C aused by • Exposed C l ubb in g areas warm may be • Expos e d a r eas cold , massage / wa r ming helps · ' - . _--- Oxygen Cyanosis may disappear in ri ht to left shunt in pulmonary case (Except Disappea rs C e n t ra l P er ip h e r a l m em bra n es o nl y a rt e ri a l oxygen sa t . o r vasoco n st ri c t ion or a b no r ma l hemoq l ob i n decreased b l ood flow p r e s en t • N o clu bb i nq

18. • Cold • M@ t ­ • Sh un t cardiac output Pe r i l pheral cyanosis Cen t r al eya osis • Polycythemia • A lt i tude • Obst ruct t o n • Lung disease • l VF a n d s h ock sulfhemoglobinemia • Decreased Mnemonic: h ' COLD PALMS"

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

20. Approach to Cyanosis ry Onse t ? Is the cyanosis of recent onset or has it b een p resent since bi r th ? A 1. hi s t ory of cy a n os i s s in ce bi r th a nd "s q uatt i n g" in c hild h oo d s u gges t co n ge ni t a l h e a rt di sease. C hr o ni c cy a n o s i s caus e d b y m e th emo g l o bin e m i a c a n b e co n ge ni t a l o r a c quir e d . Oth e r causes of chr o nic cy a n os i s in c lud e c hr o ni c ob s truct i ve pul m o n a r y di sease (C OPD ) , pulmo n a r y fibr os i s , a nd pulmo n a r y a tr i ove ntr i c ul a r fi s tula. A cu t e a nd s ub a cu t e c ya no s is c a n b e c aus e d b y a cu t e m yo cardial pn e umoni a , or upp e r ai r w a y infarct i o n, pn e umo t hora x, o b s truction. pulmo n a r y e mbolu s , 2. Symptomati c ? As ymptomatic pat i e nts m a y ha ve m e th e mo gl obin e mia ( con ge ni tal ( pr es cri b e d Int e rmit t e nt or dru g indu c e d ) or s ulfh e mo g lobi n e mia. Ex po s ur es to dru gs an d ! or illici t ) or e n v iron m e ntal facto r s s hould b e r ev i e w e d. c y ano s i s , s kin color cha n ges , and pain w ith cold ex po s ur e s ugg es t Raynau d 's ph e nomenon. Symptomatic pa t i e n ts , es p e cial l y w ith ch es t pain a nd r es pira t ory di s tr ess , ar e mor e li k e l y t o ha ve a cardiac or pulmona r y c aus e o f cy an os i s .

21. )Y 3. R i s k Fa c t ors? D oes t h e patient h ave kn ow n ri s k facto r s for card i a c or 4. Fa mi l y Hi s tor y or Pa s t M e di c al His t o r y ? Is th e r e a fami l y hi s to ry o f / pulmo n a r y di seas e , in c lu d in g s m oking , h ype rlipidemi a , a s thm a , d r u g a b use (e s pecial l y m eth a mph et a mi n es ) , sev e r e obe s i ty (s l e e p a pn ea ) , neuromuscu l a r d iseas e , or a u to immu n e di se a s e ? Doe s th e p a t i e n t h ave ch es t pa i n o r i n te r mit t e n t c yanosis w i t h exer c i se , s u ggesting ang i n a? C h est pain c a n b e pr es e nt with acu t e pulmona r y e mboli or pn e umot h o ra x . I s th e r e a co u gh a nd fev e r s u gge s ti n g pn e umon i a ? Has th e p a t i e nt h a d a n y oc c up a t i ona l or env i ronm e n t a l expos ur e s th at m i ght c a u se pul mo n ary pr o bl e ms ? a bn orm a l h emo g lobin or pulmo n ary d iseas e ? Has t h e p a t i e n t suffer e d a n e pi sode of hypo t ens i o n t hat co uld pr o du ce a dul t re s pir atory di s tr es s syndrom e (A RD S) , s u c h as se p s i s or h e a rt fa ilu r e?

22. B. Physic a l 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. Addi t i ona l phys i c a l 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, wheezin g , and rhonchi consistent with reactive airway disease or absence of breath sounds, suggestive of pneumonia or pneumothorax. Auscultate the heart for murmurs, arrhythmia s , 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 clubbin g , which is suggestive of chronic pulmonary

23. e oxi m e try e stima t e s oxyg e n saturation but does not m e asur e it dir e ctly. n e c e ssary Dir e ct m e asur e m e nts using ar t e rial blood gas e s (ABGs) ar e to ass e ss a pat i e nt with cyanosis. Pat i e nts with abnormal h e moglobin typ e s hav e a normal Pao , but d e cr e as e d h e moglobin O 2 saturation A low Pao , is cau s e d by r e spiratory or cardiac problems in most circumstances. 2. A ch e st radiograph h e lps ass e ss h e art si z e suggest pn e umoni a , ARD S , or pulmonary and lung par e nchyma. Infiltra t e s e dema. E xclude pneumothorax. Look for e vid e nc e of in t e rstitial lung dis e as e . Pl e ural e ffusion can r e pres e nt inf e ction, malignanc y , or pulmonary edema.

24. An e l ectrocardiogram may demonstrate ac u t e myoca r di a l infarction, ve ntr i c ul a r arrhythm i a, or p e ri c a rdial proc ess . P pulmona l e , right h ype rtroph y , and ri gh t axis shift s u gges t chronic pul m o nar y di se a se . 4. An e c h oca r di ogram can he l p diagnose b o th di a s to l i c an d systo l i c h ea r t fa ilu r e, as we ll as v i s ual i ze wa ll mo t i o n a bn orm a lit i es th a t may b e pr es e nt in a c ut e or prior m y ocardial infarction. Ev id e n ce of pul m o n a r y hyp e rt e nsion can a l so b e se e n on e c ho c a rdio gr am 5. C h est com p u ted tomogra p h y (CT) may i d en t i fy p ul monary emb o l i c a rdi ac an d a nd p rov id e mo re inf o r m a t i o n th a n c h es t x - ray in a var i ety o f pulmo n a r y d b is e a ses . ~~~~)ocar d l Ogram , ~ ~ ~ Computer reCO«ls $01100 WQII'C ~ , nd ol$pln y s picWfe 1 P8tlen1.oes on be<! on lie n side Sooogra p hCf moves I r8l\SdIJ«( o n palAn!', cIloo$ l H • • r1 Electrode pa l cl10s aUo c he d 1 cnesc ( 1Of EKCl )

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