Cyanosis resident survival guide (pediatrics): Difference between revisions
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==Overview== | ==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 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 etiology and emergent cases with respiratory distress need rapid evaluation and response with immediate establishment of airway access and oxygen support. | |||
==Causes== | ==Causes== | ||
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==FIRE: Focused Initial Rapid Evaluation== | ==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. | 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]]]. | *A Focused Initial Rapid Evaluation (FIRE) should be performed to identify the [[patients]] in need of immediate [[intervention]]]. | ||
{{Family tree/start}} | {{Family tree/start}} | ||
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{{familytree |D01| |D02| | |D03| |D04| | |D05| |D06| | |D07| |D01=[[TGA]], [[TAPVR ]],[[Truncus arteriosus]]|D02= [[TOF]]|D03=Ebstein anomaly |D04=[[Hypoplastic left heart syndrome]] |D05=[[Sepsis]], [[shock]], low [[cardiac output]] state, [[cold exposure]], [[metabolic disorder]], [[polycythemia]] |D06=[[Eisenmenger syndrome]] with [[pulmonary hypertension]] |D07=Methemoglobinemia }} | {{familytree |D01| |D02| | |D03| |D04| | |D05| |D06| | |D07| |D01=[[TGA]], [[TAPVR ]],[[Truncus arteriosus]]|D02= [[TOF]]|D03=Ebstein anomaly |D04=[[Hypoplastic left heart syndrome]] |D05=[[Sepsis]], [[shock]], low [[cardiac output]] state, [[cold exposure]], [[metabolic disorder]], [[polycythemia]] |D06=[[Eisenmenger syndrome]] with [[pulmonary hypertension]] |D07=Methemoglobinemia }} | ||
{{familytree | |!| | | |!| | | |!| | | |!| | | | |!| | | | |!| | | | | |!||}} | {{familytree | |!| | | |!| | | |!| | | |!| | | | |!| | | | |!| | | | | |!||}} | ||
{{familytree |D01| |D02| | |D03| |D04| |D05| | |D06| | |D07| | |D01= Infusion of [[Prostaglandin]], [[Diuretic]] therapy,surgery <ref name="Rao2013">{{cite journal|last1=Rao|first1=P. Syamasundar|title=Consensus on Timing of Intervention for Common Congenital Heart Diseases: Part II - Cyanotic Heart Defects|journal=The Indian Journal of Pediatrics|volume=80|issue=8|year=2013|pages=663–674|issn=0019-5456|doi=10.1007/s12098-013-1039-2}}</ref>|D02= | {{familytree |D01| |D02| | |D03| |D04| |D05| | |D06| | |D07| | |D01= Infusion of [[Prostaglandin]], [[Diuretic]] therapy,surgery <ref name="Rao2013">{{cite journal|last1=Rao|first1=P. Syamasundar|title=Consensus on Timing of Intervention for Common Congenital Heart Diseases: Part II - Cyanotic Heart Defects|journal=The Indian Journal of Pediatrics|volume=80|issue=8|year=2013|pages=663–674|issn=0019-5456|doi=10.1007/s12098-013-1039-2}}</ref>|D02=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]]|D03=[[Tricuspid valve]] repair<ref name="pmid31384377">{{cite journal |vauthors=Holst KA, Connolly HM, Dearani JA |title=Ebstein's Anomaly |journal=Methodist Debakey Cardiovasc J |volume=15 |issue=2 |pages=138–144 |date=2019 |pmid=31384377 |pmc=6668741 |doi=10.14797/mdcj-15-2-138 |url=}}</ref>|D04=[[Hypoplastic left heart syndrome]] |D05=Treatment of underlying disorder|D06=[[Phosphodiesterase-5 inhibitor ]] ([[sildenafil]], [[tadalafil]]), [[Endothelin receptor antagonist]] ([[ bosentan]],[[ macitentan]], [[ambrisentan]])<ref name="pmid28536680">{{cite journal |vauthors=de Campos FPF, Benvenuti LA |title=Eisenmenger syndrome |journal=Autops Case Rep |volume=7 |issue=1 |pages=5–7 |date=2017 |pmid=28536680 |pmc=5436914 |doi=10.4322/acr.2017.006 |url=}}</ref>|D07=Infusion of [[ Methylenblue]],[[dextrose]],[[N-acetyl cystein]] }} | ||
{{familytree/end}} | {{familytree/end}} | ||
==Do's== | ==Do's== | ||
*Quickly think about [[hypoplastic left heart syndrome]] In infants with sudden onset of [[shock]] , [[collapse]] and severe [[academia]] in the first week of life, as well as neonate [[sepsis]] and [[metabolic disorders]].<ref name="pmid28356795">{{cite journal |vauthors=Gobergs R, Salputra E, Lubaua I |title=Hypoplastic left heart syndrome: a review |journal=Acta Med Litu |volume=23 |issue=2 |pages=86–98 |date=2016 |pmid=28356795 |pmc=5088741 |doi=10.6001/actamedica.v23i2.3325 |url=}}</ref> | *Quickly think about [[hypoplastic left heart syndrome]] In infants with sudden onset of [[shock]] , [[collapse]] and severe [[academia]] in the first week of life, as well as neonate [[sepsis]] and [[metabolic disorders]].<ref name="pmid28356795">{{cite journal |vauthors=Gobergs R, Salputra E, Lubaua I |title=Hypoplastic left heart syndrome: a review |journal=Acta Med Litu |volume=23 |issue=2 |pages=86–98 |date=2016 |pmid=28356795 |pmc=5088741 |doi=10.6001/actamedica.v23i2.3325 |url=}}</ref> | ||
*In [[ebstein anomaly]] repair of [[tricuspid valve]] indicates if there is :[[Cyanosis]], [[Right-side heart failure]], Poor [[functional capacity]], [[Paradoxical emboli]]<ref name="pmid31384377">{{cite journal |vauthors=Holst KA, Connolly HM, Dearani JA |title=Ebstein's Anomaly |journal=Methodist Debakey Cardiovasc J |volume=15 |issue=2 |pages=138–144 |date=2019 |pmid=31384377 |pmc=6668741 |doi=10.14797/mdcj-15-2-138 |url=}}</ref>. | *In [[ebstein anomaly]] repair of [[tricuspid valve]] indicates if there is :[[Cyanosis]], [[Right-side heart failure]], Poor [[functional capacity]], [[Paradoxical emboli]]<ref name="pmid31384377">{{cite journal |vauthors=Holst KA, Connolly HM, Dearani JA |title=Ebstein's Anomaly |journal=Methodist Debakey Cardiovasc J |volume=15 |issue=2 |pages=138–144 |date=2019 |pmid=31384377 |pmc=6668741 |doi=10.14797/mdcj-15-2-138 |url=}}</ref>. |
Revision as of 07:06, 13 October 2020
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 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 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 |
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Decreased inspired FiO2
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Upper airway obstruction |
Pulmonary vascular disorders |
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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
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Pysical Examination
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Diagnostic Studies
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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.
| Depending upon etiology
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,surgery [1] | 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[2] | Hypoplastic left heart syndrome | Treatment of underlying disorder | Phosphodiesterase-5 inhibitor (sildenafil, tadalafil), Endothelin receptor antagonist (bosentan,macitentan, ambrisentan)[3] | Infusion of Methylenblue,dextrose,N-acetyl cystein | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do's
- Quickly think about hypoplastic left heart syndrome In infants with sudden onset of shock , collapse and severe academia in the first week of life, as well as neonate sepsis and metabolic disorders.[4]
- In ebstein anomaly repair of tricuspid valve indicates if there is :Cyanosis, Right-side heart failure, Poor functional capacity, Paradoxical emboli[2].
- In differential cyanosis if oxygen saturation of right arm is more than legs and improves with O2 supplemental therapy, think about severe coarctation of aorta, aortic arch interruption, primary pulmonary hypertension.
- In the presence of central cyanosis + hemolytic anemia (jundic,heinze body,fragment RBC)+ renal failure consider about methemoglobinemia.
- Quickly correct dehydration and any distress in infants with cyanotic tet spell in Tetralogy of Fallot to maintain pulmonary blood flow through atretic pulmonary artery and reducing right to left shunt through VSD.[5]
- Think about paradoxical embolism and do a Brain CT scan in the precence of new neurologic symptoms in cyanotic congenital heart disease because of passing the emboli from right to left shunt and hyperviscosity leading to thrombosis.[6]
Don'ts
- Cyanotic congenital heart diseases that pulmonary congestion is independent on patent ductus arteriosus(PDA) do not worsen with dehydration include :
- Transposition of great arteries(TGA)
- Truncus arteriosus(TA)
- Total anomalous pulmonary venous connection(TAPVR)[7]
References
- ↑ 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.
- ↑ 2.0 2.1 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. - ↑ 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)
- ↑ 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.
- ↑ O’Brien, Patricia; Marshall, Audrey C. (2014). "Tetralogy of Fallot". Circulation. 130 (4). doi:10.1161/CIRCULATIONAHA.113.005547. ISSN 0009-7322.
- ↑ . doi:10.1161/STROKEAHA.116.012882Stroke. Missing or empty
|title=
(help) - ↑ Kim HS, Jeong K, Cho HJ, Choi WY, Choi YE, Ma JS, Cho YK (December 2014). "Total anomalous pulmonary venous return in siblings". J Cardiovasc Ultrasound. 22 (4): 213–9. doi:10.4250/jcu.2014.22.4.213. PMC 4286644. PMID 25580197.