Cyanosis resident survival guide (pediatrics)

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Resident
Survival
Guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usman Ali Akbar, M.B.B.S.[2]

Synonyms and Keywords: Cyanosis approach in children, Cyanosis workup pediatrics, Cyanosis management in newborn, Approach to blue discoloration of skin in infants, Hypoxemia approach in children, Hypoxia approach in children

Cyanosis resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Cyanosis can be defined as bluish discoloration of skin and mucosa and can also be a manifestation of oxygen desaturation of arterial or capillary blood. Cyanosis, hypoxemia, and hypoxia should be differentiated and can occur independently. The causes of cyanosis in a newborn range from congenital cardiac conditions to life-threatening conditions such as exposure to toxic gases or infections leading to sepsis. The management of cyanosis depends upon the etiology and emergent cases with respiratory distress need rapid evaluation and response with immediate establishment of airway access and oxygen support.

Causes

Life-Threatening Causes Pulmonary Causes Congenital Cardiac Conditions Hematological Causes Peripheral Cyanosis
Decreased inspired FiO2
Upper airway obstruction

Pulmonary vascular disorders

Other Causes

FIRE: Focused Initial Rapid Evaluation

  • A Focused Initial Rapid Evaluation (FIRE) should be performed to identify the patients in need of immediate intervention.[3]
 
 
 
 
 
 
 
 
 
Patient presents with cyanosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No Respiratory Distress
 
 
 
 
 
 
 
 
 
 
 
 
Respiratory Distress
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Peripheral Cyanosis
 
Central cyanosis
 
Differential Cyanosis
 
 
 
No Obstruction
 
 
 
Obstruction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reassurance and Warming
 
Hypoxia Test
 
Cardiac Evaulation
 
 
 
Hypoxia Test
 
 
 
Give oxygen and Positive Pressure Ventilation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PaO2<100
 
PaO2 100-150
 
PaO2 <100
 
PaO2 100-150
 
PaO2 >150
 
ENT Evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cardiac Evaluation
 
Persistent pulmonary hypertension of newborn, Cardiac Evaluation
 
Cardiac Cause
 
Persistent pulmonary hypertension of newborn
 
Respiratory management, Give oxygen and positive pressure Ventilation

Complete Diagnostic Approach

 
 
 
Patient presents with cyanosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic Studies
 
 

Treatment

 
 
 
 
 
 
 
Treatment depends upon the etiology of cyanosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Respiratory Compromise
 
 
 
 
 
 
 
No Respiratory Compromise
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*An adequate airway should be established and supplemental oxygen is given.
 
 
 
 
 
 
 
Depending upon etiology
  • Sepsis: Broad-spectrum antibiotics should be initiated such as ampicillin and gentamicin.
  • Blood cultures should be obtained to identify the causative agent.

     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    TGA, TAPVR ,Truncus arteriosus
     
    TOF
     
     
    Ebstein anomaly
     
    Hypoplastic left heart syndrome
     
     
    Sepsis, shock, low cardiac output state, cold exposure, metabolic disorder, polycythemia
     
    Eisenmenger syndrome with pulmonary hypertension
     
     
    Methemoglobinemia
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Infusion of prostaglandin, diuretic therapy, and surgery.[5]
     
    Infusion of prostaglandin for keeping patency of ductus arteriosus, infusion of vasodilator for reduced systemic resistance, mechanical ventilation in shock state and imposing hypercapnia and alveolar hypoxia for increased pulmonary resistance
     
     
    Tricuspid valve repair[6]
     
    Hypoplastic left heart syndrome
     
    Treatment of underlying disorder
     
     
    Phosphodiesterase-5 inhibitor (sildenafil, tadalafil). Endothelin receptor antagonist (bosentan,macitentan, ambrisentan).[7]
     
     
    Infusion of methylene blue, dextrose, N-acetyl cysteine
     
     

    Do's

    Don'ts

    References

    1. McMullen, SM; Patrick, W (2013). "Cyanosis". The American journal of medicine. 126 (3): 210–2. doi:10.1016/j.amjmed.2012.11.004. ISSN 0002-9343. PMID 23410559.
    2. Sasidharan, Ponthenkandath (2004). "An approach to diagnosis and management of cyanosis and tachypnea in term infants". Pediatric clinics of North America. Elsevier BV. 51 (4): 999–1021. doi:10.1016/j.pcl.2004.03.010. ISSN 0031-3955. PMID 15275985.
    3. 3.0 3.1 Dasgupta, Soham; Bhargava, Vidit; Huff, Monica; Jiwani, Amyn K.; Aly, Ashraf M. (2016-09-30). "Evaluation of The Cyanotic Newborn: Part I—A Neonatologist's Perspective". NeoReviews. American Academy of Pediatrics (AAP). 17 (10): e598–e604. doi:10.1542/neo.17-10-e598. ISSN 1526-9906.
    4. "Congenital Heart Disease". NCBI Bookshelf. 2010-07-22. Retrieved 2020-10-13.
    5. Rao, P. Syamasundar (2013). "Consensus on Timing of Intervention for Common Congenital Heart Diseases: Part II - Cyanotic Heart Defects". The Indian Journal of Pediatrics. 80 (8): 663–674. doi:10.1007/s12098-013-1039-2. ISSN 0019-5456.
    6. 6.0 6.1 Holst KA, Connolly HM, Dearani JA (2019). "Ebstein's Anomaly". Methodist Debakey Cardiovasc J. 15 (2): 138–144. doi:10.14797/mdcj-15-2-138. PMC 6668741 Check |pmc= value (help). PMID 31384377.
    7. de Campos F, Benvenuti LA (2017). "Eisenmenger syndrome". Autops Case Rep. 7 (1): 5–7. doi:10.4322/acr.2017.006. PMC 5436914. PMID 28536680. Vancouver style error: initials (help)
    8. Gobergs R, Salputra E, Lubaua I (2016). "Hypoplastic left heart syndrome: a review". Acta Med Litu. 23 (2): 86–98. doi:10.6001/actamedica.v23i2.3325. PMC 5088741. PMID 28356795.
    9. O’Brien, Patricia; Marshall, Audrey C. (2014). "Tetralogy of Fallot". Circulation. 130 (4). doi:10.1161/CIRCULATIONAHA.113.005547. ISSN 0009-7322.
    10. . doi:10.1161/STROKEAHA.116.012882Stroke. Missing or empty |title= (help)