A Dusky Hypoxic Woman

Craig Smollin MDAssociate Medical Director

California Poison Control Center - SF Div.

Blue man case #1

• A 46 year-old male was sent to the emergency department for cyanosis. In the emergency department he appeared in no acute distress and had obvious blue-gray discoloration of the skin. Vital signs were BP 148/81, P 88, RR 16, O2 sat 98%, Temp afebrile. The rest of the exam is unremarkable.

Blue man case #2

• A 34 year old HIV+ woman presents with c/o feeling lightheaded, nauseated, and short of breath. Vital signs were BP 124/88, P 116, RR 18 , O2 sat 82% NRB, Afebrile. She was in no respiratory distress but appeared to have blue discoloration of the lips, gums, face and peripherally in the digits and nail beds. The rest of the exam was unremarkable.

What is cyanosis?

• Blue discoloration due to hypoxemia.

• Central vs. peripheral

• First visible on lips and tongue.

• Deoxygenated hgb = 3.5 g/dL in arterial blood.

• O2 sat 73-78%

• Cyanosis is an unreliable sign of hypoxemia.

Cyanosis unreliable sign of hypoxemia

Cyanosis unreliable sign of hypoxemia

Cyanosis unreliable sign of hypoxemia

Approach to the blue patient

Blue man case #1

• A 46 year-old male was sent to the emergency department for cyanosis. In the emergency department he appeared in no acute distress and had obvious blue-gray discoloration of the skin. Vital signs were BP 148/81, P 88, RR 16, O2 sat 98%, Temp afebrile. The rest of the exam is unremarkable.

Blue man case #1• A 46 year-old male was sent to the

emergency department for cyanosis. In the emergency department he appeared in no acute distress and had obvious blue-gray discoloration of the skin. Vital signs were BP 148/81, P 88, RR 16, O2 sat 98%, Temp afebrile. The rest of the exam is unremarkable.

• ABG: 7.45, PCO2 35, PO2 133, lactate 1.8

• What is the diagnosis?

Blue man case #1

• On further questions the patient admits to the use of colloidal silver for the treatment of chronic MRSA infection of the skin. He purchased the product over the internet and has been using it regularly over the past year. During that time, he has noticed a gradual change in his skin color to the current blue-gray appearance.

Argyria

Blue man case #2

• A 34 year old HIV+ woman presents with c/o feeling lightheaded, nauseated, and short of breath. Vital signs were BP 124/88, P 116, RR 18 , O2 sat 82% NRB, Afebrile. She was in no respiratory distress but appeared cyanotic in the lips, gums, face and peripherally in the digits and nail beds. The rest of the exam was unremarkable.

Blue man case #2

• A 34 year old HIV+ woman presents with c/o feeling lightheaded, nauseated, and short of breath. Vital signs were BP 124/88, P 116, RR 18 , O2 sat 82% NRB, Afebrile. She was in no respiratory distress but appeared cyanotic in the lips, gums, face and peripherally in the digits and nail beds. The rest of the exam was unremarkable.

• ABG = 7.44, PCO2 31, PO2 307, Lactate 1 0

Approach to the blue patient

Blue man case #2• A 34 year old HIV+ woman presents with c/o feeling lightheaded, nauseated, and short of breath. Vital signs were BP 124/88, P 116, RR 18 , O2 sat 82% NRB, Afebrile. She was in no respiratory distress but appeared cyanotic in the lips, gums, face and peripherally in the digits and nail beds. The rest of the exam was unremarkable.

• ABG = 7.44, PCO2 31, PO2 307, Lactate 1.0

• MetHb = 41%

Common drugs and toxins causing methgb

Met-hgb Pathophysiology

Hemoglobin

Oxygen

Met-Hgb

1. Functional Anemia

2. Shift in Oxygen HgbDissociation Curve

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Met-Hgb Pathophysiology

• Hemoglobin

• Fe oxidized to Fe3+

• Functional anemia

• Changes hemoglobin such that it wont give up oxygen

Symptoms and Signs

Methemaglobinemia

• Treatment:

• Methylene blue

• Dosed IV 1-2 mg/kg of a 1% solution over 5 minutes (max dose = 7 mg/kg)

• Symptoms generally improve over 1 hour

• General rule treat when methgb level > 20%