What area is best for assessing central cyanosis

Q.  Is cyanosis a sign of a heart attack?

1. In heart failure, lung embolism, pneumonia, or acute severe attack of asthma, the cyanosis may have a sudden or abrupt onset as the patient ‘begins to turn blue’ due to lack of oxygen. On the other hand, patients with chronic obstructive lung disease or COPD often develop cyanosis gradually over many years.

Q.  Should I treat blue lips in my child?

1. It's common for new-borns to have some areas of blue skin once in a while. But if your baby's lips, mouth, head, or trunk are blue, seek emergency medical help.

Q.  What's the cause of my baby's skin turning blue?

1. There are two reasons why the blood under your baby's skin may look blue:

1. The lungs are not getting enough oxygen. Since it is the oxygen that makes the blood turn red in colour, blood cells without oxygen remain blue.
2. The underlying blood is displays a slow movement, so the normal veins underneath that carrying blue, oxygen-poor blood back to the heart are more noticeable.

Q.  Can anemia cause cyanosis?

1. Cyanosis is caused by an increase in the deoxygenated hemoglobin level to above 5 g/dL. Patients who have anemia do not develop cyanosis until the oxygen saturation (also called SaO2) falls below normal hemoglobin levels.

Q.  How long does Cyanosis last?

1. It is a common finding and may persist for 24 to 48 hours. Central cyanosis caused by reduced arterial oxygen saturation lasts for nearly 5 to 10 minutes in a newborn infant as the oxygen saturation rises to 85 to 95 percent by 10 minutes of age.

Q.  How to differentiate between mild cyanosis and severe cyanosis?

1. Babies who suffer from cyanotic heart disease are often referred to as “Blue Babies”. To determine if the cyanosis is mild or severe can be done by analyzing the following:

   In general, cyanosis is known to worsen with activity, and only proper resting can one bring it down. Dark skin complexion and the presence of anemia can often make it hard for the parents and doctors alike to recognize signs of mild cyanosis.

Q.  Which speciality doctor should I consult in case my baby has Cyanosis?

1. You should immediately go to the emergency room at the nearest hospital. The doctor there will refer you to a neonatologist.

Q.  Why do my nails look a bit bluish or purplish in colour ?

1. Blue or purple nails, especially the area around the base of the nails can be caused by a condition called Cyanosis. You may notice it on other parts of your body too, such as lips, palms of the hands, soles of the feet, or even earlobes.

Q.  How are Cyanosis and hypoxia related?

1. Cyanosis is a late-stage symptom of hypoxia, where vasoconstriction of the Peripheral blood vessels or decreased haemoglobin are responsible for the bluish cast of the skin.

Q.  Why does Cyanosis occur?

1. Cyanosis occurs due to lack of oxygen in the blood. It happens when the tissues of the body do not receive blood with the requisite levels of oxygen, for a variety of reasons.

Q.  Is Cyanosis a serious condition?

1. Cyanosis could be considered a significantly serious condition that requires immediate medical attention.

Q.  What’s the primary difference between Peripheral and Central Cyanosis?

1. Peripheral cyanosis is primarily caused in an individual due to low blood pressure, Raynaud’s syndrome (fingers and toes become painful and blue in cold temperatures), hypothermia, heart failure, etc. The skin turning bluey-green, affected body part feels cold to the touch are common signs of identifying whether you’re suffering from peripheral cyanosis or not. The key difference between peripheral and central cyanosis is that the former affects an individual’s hands or legs, and other external body parts like fingernails, feet, etc. and can be seen either on one side of the body or both the sides in equal proportions. The latter i.e., Central cyanosis affects the core organs of the body causing a blue-green tint across lips, tongue, and unlike peripheral, symptoms of central cyanosis don’t get better when the body part is heated up. In both forms of cyanosis, you would notice problems with the heart, lungs, or nervous system.

Q.  What is Peripheral Cyanosis?

1. Cyanosis refers to a blue tint to the skin and mucous membranes. Peripheral Cyanosis is a condition wherein there is a bluish discoloration to your hands or feet. It is generally said to be usually caused by low oxygen levels in the red blood cells or problems getting oxygenated blood to your body. Blood that’s rich in oxygen is the bright red colour typically associated with blood. When blood has a lower level of oxygen and becomes a darker red, more blue light is reflected, making the skin appear to have a blue tint.

1. In some cases, cold temperatures are said to cause blood vessel narrowing and lead to temporarily blue-tinged skin. Warming or massaging the blue areas should return normal blood flow and colour to the skin.

Q.  What is Central Cyanosis?

1. Central Cyanosis is a condition that is often caused due to a circulatory or ventilatory issue that leads to poor blood oxygenation in the lungs. It generally occurs when arterial oxygen saturation drops below 85% or 75%.

Q.  What is Differential Cyanosis?

1. It is the term used for conditions where the Cyanosis is present in certain parts and absent in others.

• Only of lower limbs: due to patent ductus arteriosus (PDA) with reversal of shunt.
• Only of upper limbs: due to PDA with reversal of shunt in transposition of great vessels.
• Cyanosis of left upper and both lower limbs: due to PDA with reversal of shunt and pre-ductal coarctation of the aorta.

Q.  What is Pseudocyanosis?

1. Pseudocyanosis is a condition that’s prevalent when a bluish tint is observed on the skin and/or mucous membranes; however, there may not be hypoxemia or Peripheral vasoconstriction.

1. This condition is normally prevalent when there is an absence of either heart or lung disease and the skin also does not blanch under exertion of pressure.
2. It has been found out that common metals like silver, lead or even drugs like phenothiazines, amiodarone, chloroquine hydrochloride, usually cause this condition.

Q.  Why does my tongue have a bluish or purple cast or spotting?

1. The consumption of certain foods and beverages are normally the most common cause of a purple tongue, or spotting.

1. If no such foods or beverages are consumed, then these causes of tongue staining with a purple or blue tint can be ruled out. This could then be a sign that the blood isn’t delivering adequate oxygen to the body’s tissues. Or, that blood with low oxygen levels, which is normally dark red, rather than bright red — is what is circulating through the arteries.
2. The blueish tint or cast that is seen due to this condition is called cyanosis. Cyanosis can also be caused by conditions that impact the lung or heart, like coronary artery disease or chronic obstructive pulmonary disease (COPD). This blue tint may be prevalent in places other than just the tongue.
3. The tongue can also turn bluish or purple due to low oxygen levels or an obstruction in the airways.

In situations like these, a purple or blue tongue is the sign of a medical emergency. Seeking emergency medical aid if the tongue is discoloured, appears suddenly or is even seen to be accompanied by:

• gasping for breath
• breathing difficulties
• pain in the chest
• dizziness
• fainting

Q.  How to check for Cyanosis?

1. Pulse oximetry, coupled with clinical symptoms can quickly diagnose Cyanosis.

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Definition and PathogenesisTop

Cyanosis is characterized by abnormal bluish discoloration of the skin and mucous membranes. It is caused by increased concentration of deoxygenated hemoglobin in the capillary blood (>3.1 mmol/L [50 g/L]) or presence of an abnormal hemoglobin (most frequently methemoglobin >0.31 mmol/L or [5 g/L]).

1. Central cyanosis: Generalized, visible on the mucous membranes (mainly lips) and skin, which is usually warm. As cyanosis may not be clearly apparent in patients with darker skin pigmentation, close evaluation of the nail beds, tongue, and mucous membranes is critical. Causes:

1) Hypoxemia (usually hemoglobin oxygen saturation (SaO2) <85%, partial pressure of oxygen (PaO2) <60 mm Hg): Ventilation-perfusion mismatch (obstructive lung disease, pulmonary embolism), impaired diffusion (pulmonary fibrosis), shunt (alveolar collapse, congenital heart disease [right to left shunting], pulmonary arteriovenous malformation), decreased oxygen partial pressure in inhaled air (at high altitudes).

2) Presence of a pathologic hemoglobin: Methemoglobinemia (congenital or acquired), sulfhemoglobinemia (in such cases PaO2 is normal).

2. Peripheral cyanosis: Visible only over the skin of distal body parts, where blood flow is less rapid. The skin is usually cold. When present over the pinna, it disappears with pressure. Peripheral cyanosis is a manifestation of excessive deoxygenation (increased oxygen extraction) of hemoglobin in peripheral tissues. Normal arterial oxygen saturation (SaO2) is usually observed. Causes:

1) Significant hypothermia (physiologic vasoconstriction).

2) Decreased cardiac output (eg, cardiogenic shock, advanced heart failure, mitral or aortic stenosis).

3) Local abnormalities of arterial circulation (eg, atheroma, arterial emboli, Buerger disease, diabetic angiopathy).

4) Vasomotor disturbances (anxiety-related, Raynaud phenomenon, acrocyanosis).

5) Impaired venous drainage (thrombosis, postthrombotic syndrome, superficial vein phlebitis).

6) Increased blood viscosity (polycythemia vera, cryoglobulinemia, gammopathy).

3. Pseudocyanosis: As opposed to central and peripheral cyanosis, this does not disappear with the application of pressure to the skin. It is a rare phenomenon. Causes: abnormal pigmentation of the skin (drugs: chlorpromazine, amiodarone, minocycline; exposure to heavy metals, eg, to silver [argyria] or gold [chrysiasis]).

DiagnosisTop

1. Assess stability (mental status, airway patency, respiratory distress) and vital signs (respiratory rate, pulse, blood pressure, body temperature, pulse oximetry).

2. Take a focused history (timing of cyanosis, exposures) and perform physical examination (central or peripheral cyanosis; exclude pseudocyanosis; assess respiratory and cardiovascular systems).

3. Co-oximetry provides a more accurate assessment of oxygen saturation as it measures absorption of light at 4 different wavelengths, including oxyhemoglobin, deoxyhemoglobin, carboxyhemoglobin, and methemoglobin.

4. Perform arterial blood gas analysis (cyanosis is not a reliable sign of hypoxemia) and measurement of carboxyhemoglobin and methemoglobin levels.

5. Assess response to oxygen therapy. Response is poor in patients with cyanotic congenital heart disease, in cases of significant pulmonary shunts of deoxygenated blood, and in patients with a pathologic hemoglobin.

6. Perform a complete blood count (CBC) (true cyanosis [central or peripheral] is masked in individuals with severe anemia and manifests earlier in those with polycythemia vera), chest radiography, and, depending on the suspected cause, other cardiovascular (electrocardiography [ECG], echocardiography, contrast-enhanced echocardiography) or respiratory (pulmonary function tests, computed tomography [CT] of the thorax) studies as well as measurement of pathologic hemoglobin levels (eg, congenital or acquired methemoglobinemia).