Paediatrics: Cyanosis - Assessment

2021-03-10 12:00 AM

Cyanosis is the result of deoxygenated haemoglobin or abnormal haemo-globin in the blood.

Cyanosis: assessment

Cyanosis is the result of deoxygenated haemoglobin or abnormal haemo-globin in the blood. Cyanosis is apparent when there is 4g/dL of reduced haemoglobin or 0.5g/dL of methaemoglobin. Anaemic patients may not become cyanotic even in the presence of marked arterial desaturation. In light-skinned patients, cyanosis is usually noted with arterial saturation <85%. In dark-skinned patients, the saturation must be lower. Cyanosis is caused by the following problems.

  • Lung pump:

alveolar hypoventilation;

ventilation-perfusion inequality;

impairment of oxygen diffusion.

  • Cardiovascular pump: right-to-left shunting.
  • Haematological: decreased affinity of haemoglobin for oxygen.

The differential diagnosis for cyanosis

Alveolar hypoventilation

  • CNS: seizures; cerebral oedema; haemorrhage; infection; hypoxia–ischaemia; drugs
  • Hypothermia

Ventilation-perfusion inequality

  • Lung: bronchiolitis; pneumonia, pneumothorax; pleural effusion; respiratory muscle dysfunction (muscular dystrophy, myasthenia gravis, Guillain–BarrĂ©); tracheal compression
  • Cardiac: decreased pulmonary blood flow (tricuspid atresia, pulmonary atresia with an intact septum, critical pulmonary stenosis, tetralogy of Fallot); decreased systemic perfusion (coarctation of the aorta, sepsis)

Impairment of oxygen diffusion

  • Lung: bronchopulmonary dysplasia; hypoplasia; diaphragmatic hernia

Right-to-left shunting

  • Cardiac: congenital heart defect; Eisenmenger syndrome; AV fistula—pulmonary or systemic
  • Decreased oxygen affinity for haemoglobin
  • Methaemoglobinaemia: hereditary; aniline dyes; nitrobenzene; azocompounds and nitrites
  • Carboxyhaemoglobinaemia

Clinical assessment

The key part of the assessment is respiratory and cardiovascular.

Vital and general signs

  • Record the temperature.
  • Record HR.
  • Record BP in all four limbs.
  • Is there evidence of failure to thrive?

Clubbing

This sign may be present in the older infant or child. It should be looked for in the fingers and toes. The causes can be:

  • hereditary;
  • idiopathic;
  • congenital heart disease (CHD);
  • infective endocarditis;
  • pulmonary conditions (e.g. cystic fibrosis);
  • GI disease (e.g. Crohn’s, ulcerative colitis, cirrhosis).

Respiratory

In the neonate increased respiratory rate (usually <80breaths/min) with no respiratory distress suggests cyanotic heart disease, but with respiratory distress, the pulmonary disease is suggested. In the older child a full respiratory examination is required—look at all components of the examinations.

Cardiovascular

The absence of a murmur does not exclude congenital heart disease. Is the liver enlarged?