Cyanosis resident survival guide (pediatrics)

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

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

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

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

Patients presenting to the emergency department with cyanosis and respiratory distress require emergency supplementation of O2, use of pulse-oximetry and airway, breathing, and circulation support.

  • A Focused Initial Rapid Evaluation (FIRE) should be performed to identify the patients in need of immediate intervention].
 
 
 
 
 
 
 
 
 
Patient present with cyanosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No Respiratory Distress
 
 
 
 
 
 
 
 
 
 
 
 
Respiratory Distress
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Peripheral Cyanosis
 
Central
 
Differential Cyanosis
 
 
 
No Obstruction
 
 
 
Obstruction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reassurance & Warming
 
Hypoxia Test
 
Cardiac Evaulation
 
 
 
Hyperoxia Test
 
 
 
Give O2 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 O2 and positive pressure Ventilation

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of [[disease name]] according the the [...] guidelines.

 
 
 
Patient presents with cyanosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History
  • Age: Certain conditions are more common in neonates than the older children such as cyanotic heart conditions and polycythemia
  • Presence/Absence of Fever: A history of fever shows the presence of existing infection
  • History of Trauma : Chest wall trauma can cause central cyanosis.
  • Exposure to toxic gases: Exposure to certain gases and smoke can cause cyanosis. Nitrates containing food can also cause methemoglobinemia.
  • Medication Induced Cyanosis: Certain medications such as amiodarone can be a cause of cyanosis.
  • Co-existing Pulmonary Pathology: Conditions such as asthma or bronchopulmonary dysplasia can result in cyanosis.
  • History of Congenital Heart Disease: Central cyanosis can be caused by a number of cyanotic congenital cardiac conditions and may result in shock.
  • History of Neurological Disease:Respiratory depression due to drug or toxin ingestion, CNS lesions, a history of seizures, breath-holding spells in infants, and neuromuscular disease should be asked and rule out while pursuing causes of cyanosis.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pysical Examination
  • Fever :An intrinsic pulmonary pathology such as pneumonia can cause fever and cyanosis in children.
  • Pulmonary Examination : Pulmonary examination may elicit flaring, grunting, retractions and respiratory distress. Tachypnea is an important finding in patient with respiratory cause of cyanosis. An upper airway obstruction can cause stridor. Pulmonary edema can cause rales or crackles.Clear lung sounds may be associated with cardiac conditions which cause cyanosis. Injury to lung may present with abnormal chest wall movement, sucking chest wound, ecchymosis on chest wall, tracheal deviation, subcutaneous crepitus and abnormal breathing sounds.
  • Cardiac Examination: Look for cardiac murmur.A loud or single second heart sound can be present in cyanotic cardiac conditions or pulmonary hypertension.
  • Skin Examination : Cold exposure can cause peripheral vasoconstriction causing cyanosis whereas central cyanosis due to methemoglobinemia may present with gray appearing skin.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic Studies
  • CBC with differential : An elevated white blood cell may indicate infection.
  • Arterial Blood Gases:
  • PaO2>150 mmHg may indicate Pulmonary Parenchymal Disease
  • PaO<150 and Normal PCO2 shows the presence of Intra or Extra-Pulmonary Right to Left Shunts.
  • PaO2>150 mmHg and elevated PCO2 may cause central hyperventilation.
  • PaO2 <150 mm Hg, usually <50 mmHg and normal PCO2 may include transposition physiology.
  • Normal PaO2 and PCO2 may be due to hemoglobin disorders.
  • Hematocrit : Polycythemia or elevated hematocrit may be present in plethoric children.
  • Chest X-ray:Chest X-ray may show findings in pulmonary pathology. Egg-on-end appearance and pulmonary venous congestion may be present in transposition of great arteries.
  • ECG : It is helpful in congenital cardiac conditions. This can be sometimes augmented with echocardiography to specifically identify cardiac pathology.
  • Methemglobinemia serum level: It is measured in cyanotic patient switch normal PaO2 with excluded cardiac pathology. Difference between calculated oxygen saturation on ABGs analysis and direct measurement by co-oximetry may indicate methemoglobinemia.
  • Differential Saturation(pre-ductal vs post-ductal): Its is absent in pulmonary parenchymal disease and present if there is right to left shunt at ductus arteriosus.Post ductal differential saturation is present in transposition of great arteries.
 
 

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

 
 
 
 
 
 
 
Treatment Depends upon the etiology of cyanosis.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Respiratory Compromise
 
 
 
 
 
 
 
No Respiratory Compromise
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*An adequate airway should be established and supplemental oxygen is given.
  • Continuous positive airway pressure (CPAP) or intubation for positive pressure ventilation can be done for infants with respiratory distress and carbon dioxide retention.
  • If there is airway obstruction prone positioning or oral airway is established to relieve cyanosis.
 
 
 
 
 
 
 
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.

    • Neonatal Hypoglycemia : Adequate blood glucose should be maintained in range of >45 to 50 mg/dl
    • Cyanotic Congenital Cardiac Conditions should be approached with proper pediatric consultation.
    • Prostaglandin E1 should be infused at 0.01-0.05mcg/kg/min.
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     

    Congenital Cardiac Conditions


     
     
     

    Do's

    • The content in this section is in bullet points.

    Don'ts

    • The content in this section is in bullet points.

    References