Dr Sudipta Paul
Cyanosis is a very common sign comes in paediatrics clinic. It is appearing like bluish discolouration of the skin and mucous membrane. It has a significant impact on health and makes physician think of some critical disease.
KEYWORDS: Cyanosis, cyanotic heart disease, haemoglobin, homoeopathy
We are living at 21st century, but the incidences of cyanotic diseases which are from heart and pulmonary diseases are increasing day by day. Cyanotic heart diseases is highly increasing throughout the world. Cyanosis is one of the top most cases which comes in primary visit to physician. The incidence rate is high in between paediatrics age group.
Homoeopathy treat the sick individual, not the single disease entity. In many homoeopathic medicine we see that there is a symptom of ‘bluish discolouration of skin or mucous membrane’ so these medicines can be used as primary management in controlling a case of cyanosis.
“Cyanosis” word came from Greek word “kyanos” which means “blue substance”. Cyanosis is defined as the bluish discolouration of the skin and mucous membrane, resulting from an increase in the reduced haemoglobin or of haemoglobin derivatives in the small vessels of those areas. Cyanosis occurs with more than 5gm reduced haemoglobin per 100ml of blood except in methamoglobianaemia and sulfhaemoglobinaemia.
The cyanosis depends on the 4 things-
- Total amount of haemoglobin in blood;
- Degree of unsaturation of the haemoglobin;
- State of the blood vessels which must contain the reduced haemoglobin; because as if the vessels are constricted; the amount of blood is not sufficient to impart the cyanotic colour to the overlying skin;
- Pigmentation and thickness of the skin occur.
CALCULATION OF THE PERCENTAGE OF THE REDUCED HAEMOGLOBIN:
Oxygen content of arterial blood is 19.5ml, in normal condition but the oxygen capacity is 20ml. Therefore, arterial unsaturation for oxygen is 0.5ml/100ml.
Therefore, arterial blood contains about 0.375gm. of reduced haemoglobin.
Capillary blood unsaturation =
Arterial blood unsaturation + venous blood unsaturation/ 2
As, arterial blood contains 19.5 ml of oxygen; therefore; 0.5 ml of oxygen is unsaturated haemoglobin. In venous blood, the oxygen content is 14ml, therefore; 6ml is unsaturated haemoglobin in venous blood. Average volumes % oxygen unsaturation in the peripheral blood (0.5+6/2)=3.25ml. Therefore, the reduced haemoglobin in the peripheral blood = 0.75×3.25gm=2.397gm
CAUSES OF CYANOSIS IN NEWBORN:
The basic pathology of causing respiratory distress is:
- Increased alveolar fluid content,
- Inadequate clearance of lung fluid,
- Lack or inhibition of surfactant function or reduced surface area for gas exchange
The important clinical causes are:
- Hyaline membrane disease,
- Meconium aspiration,
- Clear fluid aspiration,
- Pulmonary hypoplasia,
- Broncho pulmonary dysplasia,
- Broncho pneumonia,
- Airways obstruction,
- Transient tachypnea,
- Pulmonary oedema.
- Congenital heart disease
- Aortic stenosis,
- Coarctation of aorta,
- Cyanotic – transposition of great vessels
- Tetralogy of fallot,
- Heart failure,
- Persistent pulmonary hypertension of newborn
- Metabolic acidosis,
- Hypo or hyperthermia,
- Drugs (pethidine),
- Birth trauma,
- Intracranial injury
Clinical feature depends upon the etiology, intensity & duration of oxygen lack, plasma CO2 excess and subsequent acidosis.
It has been classified previously as-
- Asphyxia livida,
- Asphyxia pallida.
Dr. Virginia Apgar invented a scoring procedures for better understanding of the clinical state. This is known as “APGAR SCORE”, this is related to the status of oxygenation of the fetus at or immediately after birth.
|RESPIRATORY EFFORT||Apnoeic||Slow, irregular||Good crying|
|HEART RATE||Absent||Slow ( below 110 )||Over 100|
|MUSCLE TONE||Flaccid||Flexion of extrimities||Active body movements|
|REFLEX IRRITABILITY||No response||Grimace||Cough or sneeze|
|COLOUR||Blue, pale||Body pink, extrimities blue||Complete pink|
- Total score= 10
- Mild depression= 4-6
- No depression= 7-10
- Severe depression= 0- 3
The scoring is done in a newborn baby at 1minutes, 5 minutes and 15 minutes and can be tabulated as written before.
If the apgar score remains significantly depressed at 5 minutes, it should be evaluated again after 15 minutes.
APPROACH TO A CASE OF CYANOSIS IN INFANT:
There should be following aim when approaching a case of cyanosis :
- We have differentiate is the cyanosis of physiological or pathological in origin.
- We have to differentiate is this from cardiac or non- cardiac in origin.
- Finding the cases which needs urgent treatment or referral.
Now the cases can be differentiate according to-
- if the cyanosis affects the tongue (margins and undersurface), inner aspect of lips, mucous membrane of gums, soft palate, checks then it is central cyanosis and causes are-
- Anatomic shunts- atrium septal defects(ASD), ventricular septal defects(VSD), patent ductus arteriosus(PDA)
- Congenital heart diseases- Fallots tetralogy, transposition of great arteries(TGA)
- Haemoglobin abnormalities etc.
- If the cyanosis affects tip of nose, ear lobules, outer aspect of chin, lip, cheeks, tip of nail beds of fingers, toes, palms, soles then it is peripheral cyanosis and the causes are-
- Cold exposures,
- Arterial obstruction- embolus, raynauds phenomenon,
- Venous obstruction- thrombophlebitis, SVC syndrome
- Frost bite
- Congestive cardiac failure
- Artherosclerosis , burgers disease
- Mitral stenosis
- Hands red (less blue) and feet blue seen in patent ductus arteriosus with reversal shunt.
- Hands blue and feet red seen in coarctation of aorta with transposition of great vessels.
If there is presence of cyanosis in upright position then the cause may be of pulmonary arteriovenous malformation.
- Methamoglobinemia may be acquired following exposure to aniline dyes, nitrates etc.
- Advanced maternal age causes trisomy 21 associated with many congenital heart defects.
- Pulmonary hypoplasia
- Drug intake: lithium causes ebstein anomaly, fetal alcohol causes VSD and ASD
- Maternal diabetes: TGA, VSD, hypertropic cardiomyopathy.
- Congenital intrauterine infection: CMV, herpes, rubella, coxsackie virus leads to cardiac structural abnormalities or functional impairment.
- Hypothermia or hyperthermia- infection
- Tachycardia – hypovolemia
- Weak pulses- hypoplastic left heart syndrome or hypovolemia
- Pulse stronger in the upper than in the lower extrimities- coarctation of the aorta.
- Upper airways obstruction
- Loud S2 suggest pulmonary or systemic hypertension or malposition of the aorta.
- Very soft murmur- TGA
- Assymetric chest movement combined with severe distress- tension pneumothorax, diaphragmatic hernia
- Transillumination of chest- pneumothorax.
- Scaphoid abdomen: congenital diaphragmatic hernia
- Hepatospleenomegaly : congestive heart failure, congenital infection.
ONSET OF CYANOSIS IN CARDIAC LESION:
- 0-6 days: D-TGA, hypoplastic left ventricles, tetralogy of fallot
- 7-13 days: tetralogy of fallot, D-TGA, hypoplastic left ventricles, coarctation of aorta.
- 14-28 days: coarctation of aorta, tetralogy of fallot, D-TGA.
- Complete blood count:
- Increase or decrease WBC: sepsis
- Haematocrit >65% : polycythemia
- Arterial blood gases:
- Arterial PO2- confirms central cyanosis
- Increase PaCO2- pulmonary or CNS disorders, heart failure
- Decrease pH- sepsis, circulatory shock, severe hypoxemia.
- Methamoglobinemia – decrease SaO2, normal PaO2, Chocolate brown blood.
RESEARCH ON CYANOSIS IN HOMOEOPATHY:
There is a lack of research papers on cyanosis in homoeopathy. But some renowned researches and case papers are found regarding this-
- Amar Nikran, on his case paper named ‘ A case of V.S.D’ which was published in hompath.com, stated that by using Lachesis 30, he has cured 35 years old male who was suffering from V.S.D and was on oxygen for nearly 24 hours and bed-ridden who was suffering in V.S.D since childhood.
- In the children’s ward of the Royal London Homoeopathic Hospital a record is being kept of all admissions of acute bronchitis and pneumonia. In 1948, 1st 50 cases under the age of 2 there was no death.
- Between, 1948-1953, there are 92 cases of pneumonia of that 64 received homoeopathic treatment; 74 cases of acute bronchitis 62 received homoeopathic treatment and there was no death.
- In 1911, Dr. Roberson Day complied a record of 400 cases of pneumonia treated in hospital between 1900- 1910 ; the mortality rate was about 50% of average mortality rate in a number of children’s hospital. In 2 groups, the figures were considerably more in favour of homoeopathic treatment
- Hasina M Mhaishale and Dr. M.A. Mhaishale conducted a research on role of homoeopathy in perinatal mortality in Savitribai Phule KMC Hospital, Kolhapur. The study was carried out in 2021, on 30 patient from antenatal and during labour. Majority of cases are with antenatal complication 65% of cases have been recovered completely, 10% cases no improvement, 25% cases partially improved. ANC complication remedies like Apis Mellifica, Caulophyllum and Natrum Muriaticum frequently used and in cases of neonatis remedies like Antim tartaricum, Chamomilla, Sambucus, Arnica and Bromium are found to be effective.
So, there is lack of homoeopathic research in cyanosis and every homoeopath should look upon this matter.
CYANOSIS AND ITS PRIMARY MANAGEMENT WITH HOMOEOPATHY:
Homoeopathy is a science of symptomatic treatment. So, we can give primary treatment of cyanosis with homoeopathic medicine if it not a referral case or urgent cases. We can use some homoeopathic medicines in treatment of cyanosis-
- Arnica Montana: Affects the venous system inducing stasis; deathly coldness of forearm; skin blue and black; haemorrhage from nose and mouth, with great strangling and suffocation.
- Arsenicum album: Icy coldness of body; blueness aggravated after every little motion; much emaciation; cold sweat; great debility.
- Borax : Cyanosis of infants from birth, circulation irregular; face bluish, especially around mouth, nose and eyes, with blueness of finger-tips and toes; during attack the child becomes prostrate and as if suffocating; the infant become pale nearly earthly coloured.
- Carbo veg: Toes red, swollen; face cyanotic; pale, Hippocratic, cold with cold sweat; blue; mottled cheeks and red nose; veins stand out very full, remarkable blue.
- CHINA OFFICINALIS: After haemorrhage collapse with waxy paleness and coldness; the veins of the face are distended;
- DIGITALIS PURPURA: Child cannot be turned in bed or moved suddenly without nearly fainting and almost causing vomiting; eyelids, lips, tongue, nails become very blue; pulse unequal or very slow; coldness of peripheral parts; Cyanosis inequality of pulse, it varies; blue distended veins on lids, ears, lips and tongue.
- LACHESIS : Suffocating spells and increased blueness, (<) sleeping, great tenderness of all the flesh; it is very difficult to handle the infant, the least touch seems to hurt it and to leave a deeper blueness, like a bruise; child faints from slightest motion; coldness of extremities.
- LAUROCERASUS: A little exercise produces gasping for breath and increased blueness; ends of fingers and toes knobby and larger than any other part of the extremities; slow, feeble, almost imperceptible breathing with moaning; irregular beating of the heart, with slow pulse, soporous condition; (>) when lying still and in the open air, where oxygen can be inhaled.
- PHOSPHORUS: Very tall and slender children, with much oppression of breathing and swelling of feet.
- RHUS TOXICODENDRON: Face pale and bluish, especially lips; flabbiness of muscular tissue; great debility
- SECALE COR: Thin, scrawny babes with shrivelled skin, especially when there are spasmodic twitchings, sudden cries, feverishness.
- SULPHUR: To increase vitality and circulation, where other remedies failed.
- PSORINUM: To increase vitality and circulation, where other remedies failed.
Medicines will be choosen by the method of careful case taking, tracing the relationship to site, character, severity of diseases etc.
CYANOSIS IN HOMOEOPATHIC REPERTORY:
- IN SYNTHESIS REPERTORY:
- MIND- LAUGHING- cyanosis, with
- MOUTH-DISCOLORATION-Tongue-blue-accompanied by-cyanosis
- RESPIRATION-ASTHMATIC-accompanied by-cyanosis
- RESPIRATION-ASTHMATIC-accompanied by-Face; cyanosis of
- COUGH-WHOOPING- accompanied by- Face- cyanosis
- CHEST-CYANOSIS-Clavicle; region of the
- GENERALS-CONVULSIONS-cyanosis, with
- GENERALS-CYANOSIS-accompanied by
- GENERALS-CYANOSIS-accompanied by-respiration; complaints of the
- GENERALS-CYANOSIS-accompanied by- Tongue
- GENERALS-CYANOSIS-accompanied by- Tongue- blue discoloration
- GENERALS-CYANOSIS-children; in
- GENERALS-CYANOSIS- children; in- birth; from
- GENERALS-CYANOSIS-children; in- infants
- GENERALS-CYANOSIS- fever; during.
- IN KENT REPERTORY:
- GENERALITIES-CYANOSIS-infant, in
- CHEST-CYANOSIS-region of clavicle-thuja (only one medicine)
- EXTRIMITIES-DISCOLORATION-upper limbs-cyanotic (see blue)
- EXTRIMITIES-DISCOLORATION-thigh-cyanosis-Arsenic (only one medicine)
- EXTRIMITIES-DISCOLORATION-leg- cyanosis-Con, elaps (only 2 medicines)
- IN MURPHY’S REPERTORY:
- Breathing-CYANOSIS, breathing- infant, in
- Children- CYANOSIS, infants, in
- Lungs- CYANOSIS, lungs- infants, in
- IN BBCR:
- SENSATION & COMPLAINTS IN GENERAL- CYANOSIS, blue face etc.
- FACE-bluish (compare Cyanosis)
- IN BTPB:
- SENSATIONS AND COMPLAINTS-sensations-Cyanosis
- IN BOERICKE REPERTORY:
- CIRCULATORY SYSTEM- CYANOSIS
- Differential diagnosis: gupta and gupta.
- Approach to a neonate with cyanosis: afnan shamraiz; available website: slideshare.net.
- C. Allen – Keynotes & characteristics with comparisons Materia Medica added with other leading remedies & bowel nosodes.
- Pocket manual of Homoeopathic materia medica & repertory- William Boericke.
- Boenninghausen’s Therapeutic Pocket Book- T.F. Allen.
- Boger Boenninghausen’s Characteristics & Repertory with corrected abbreviations, word index and thumb index- C.M. Boger.
- John Henry Clarke – A dictionary of practical materia medica.
- Homeopathic Therapeutics by Lilienthal.
- Human Physiology: Chakraborty, Ghosh & Sahana.
- D.C. Dutta’s Textbook of obstretics.
- Repertory of the homoeopathic materia medica- J.T. Kent.
- Synthesis Repertory.
- Murphy’s Repertory
Dr. Sudipta Paul B.H.M.S.,
M.D (Hom) Paediatric 1st Year Student
Guru Mishri Homoeopathic Medical College And Hospital