Chest pain resident survival guide (pediatrics)

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

Synonyms and keywords:

Chest pain resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Chest pain is the second cardiac symptom after cardiac murmur that is referred to a pediatric cardiologist for evaluation. the most common cause of chest pain in children is idiopathic and the second cause is musculoskeletal. Although there are high worries among parents about the cardiac origin of chest pain in children, it consists low percentage of causes of chest pain. Evaluation of chest pain includes assessments of the respiratory system, gastrointestinal system, cardiac diseases and psychologic factors.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Cardiac causes such as life-threatening arrhythmia, acute coronary disease, acute pulmonary embolism, tamponade
• Abdominal aorta dissection with propagation to thoracic aorta
• Perforated peptic ulcer
• Air leak syndrome such as Pneunomothorax, pneumomediastinum

Common Causes

• Ideopathic
• Respiratory
• Musculoskeletal
• Cardiac
• Gastrointestinal
• Psychiatric

Causes of pediatric chest pain

Cardiac

Musculoskeletal ❑ Muscle pain from overuse Pectoralis major and minor muscle Intercostal muscle Latissimus dorsi muscle Serratus muscle Trapezius muscle ❑Thoracic outlet obstruction ❑Ankylosis spondylitis ❑Spondylolisthesis ❑Discitis ❑Herniated disc ❑Transverse myelitis ❑Costochondritis ❑Tietze syndrome ❑Cervical rib (C7) ❑Slipping rib ❑Precordial catch syndrome ❑Trauma ❑Child abuse ❑Fractured or contused clavicle or ribs ❑Xiphoidalgia ❑Osteomyelitis ❑Rhabdomyosarcoma ❑Myositis

Pulmonary: ❑Reactive airway disease ❑Pneumothorax ❑Pneumonia (viral, bacterial, mycobacterial, fungal) ❑Chronic cough ❑Pleural effusion ❑Pleurodynia ❑Pulmonary embolism ❑Foriegn body aspiration ❑Adenoma, carcinoma

Gastrointestinal: ❑Esophagitis ❑Esophagial diverticulum ❑Esophagial spasm ❑Esophageal rupture (boerhaave syndrome ❑Mallory weiss tear ❑Achalasia ❑Gastrointestinal reflex disease (GERD) ❑Gastritis ❑Peptic ulcer disease ❑Zollinger ellison syndrome ❑Hiatal hernia ❑Foreign body ingestion ❑Cholecystitis ❑Subdiaphragmatic abcess ❑Fitz-hugh-curtis syndrome ❑Pancreatis

Mediastinal tumors: ❑Hodgkin disease ❑T-cell lymphoma ❑Thymoma ❑Thymolipoma ❑Teratoma ❑Germ cell tumor ❑Liposarcoma

Breast disease: ❑Gynecomastia ❑Thelarce ❑Mastitis ❑Adenocarcinoma

Ingestion: ❑Cocaine ❑Tobaco ❑Methamphetamine ❑Sympathomimetic decongestants

Psychiatric: ❑Somatoform disorder ❑Stress ❑Depression ❑Hyperventillation syndrome ❑Panic attack ❑Bulemia nervosa ❑Manchhausen syndrome

Congenital lesions: ❑ Aortic stenosis ❑ Aortic aneurysm with dissection ❑ Subaortic stenosis ❑ Supravalvular aortic stenosis ❑ Ruptured sinus of valsalva ❑ Coarctation of aorta ❑ Anomalous origin of coronary arteries from pulmonary artery ❑ Coronary artery ostial stenosis or atresia ❑ Left coronary artery arising from anterior cusp ❑ Congenital coronary artery aneurysm ❑ Coronary artery fistula ❑ Mitral valva prolapse ❑ Severe pulmonary stenosis ❑ Arrhythmogenic right ventricular dysplasia

Acquired lesions: ❑Dilated cardiomyopathy ❑Hypertrophic cardiomyopathy ❑Restrictive cardiomyopathy ❑Endocarditis ❑Kawasaki ❑Myocarditis ❑Rheumatic fever ❑Myocardial infarction ❑Coronary vasospasm ❑Accelerated atherosclerosis ❑Dissection of aorta aneurysm (marfan disease) ❑Pericarditis ( infection, inflammation, constriction) ❑Post pericardiothomy syndrome ❑Partial absent of the pericardium ❑Pulmonary hypertension (primary, secondary]] ❑Eisemenger syndrome ❑Takayaso arthritis ❑Cardiac tumor ❑Pericardial neoplasm ❑Cardiac transplant (rejection, accelerated atherosclerosis)

Arrhythmia: ❑Premature atrial contraction ❑Atrial flutter ❑Atrial fibrillation ❑Supraventricular tachycardia ❑Premature ventricular contraction ❑Ventricular tachycardia

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of [[disease name]] according the the [...] guidelines.

Chest pain associated different organs

Charactristics of chest pain
Musculoscletal origin	Chest wall tenderness
	Pain aggravated with inspiration
	Muscle pain with movement
	Tenderness on palpation of costochondral junction
Respiratory origin	Chest pain secondary to acute onset of cough
	Wheezing, coughing, asthma
Gastrointestinal origin	Chest pain associated with indigestion, heart burn, vomotting
	Evidence in endoscopy: gastrointestinal relex,gastritis,
Cardiac origin	Congenital heart disease
	Kawazaki
	Arrhythmia
Psychogenic origin	School problem
	Family troubles such as parents divorce
Ideopathic	No evidence of any organic etiology or any psychologic factors

Sharp

Dull

Undefined

Duration of chest pain

Charactristics of chest pain

Associated symptoms

Chest wall tenderness

Respiratory related

Squeezing

Symptoms associated with Chest pain in children and adolescence: ❑ Cough (23.4%) ❑ Dyspnea (11%) ❑ Abdominal pain (9.7%) ❑ Palpitation (9.7%) ❑ Respiratory related (9%) ❑ Dizziness (5.8%) ❑ Post nasal drip (4.4%) ❑ Fever (5.2%) ❑ Exercise induced (2.6%) ❑ Syncope (2.6%)

Cardiac

Underlying congenital or acquired heart disease, arrhythmia, crushing chest pain, exercised induced chest pain, persistent tachycardia, hypotension, gallop rhythm, syncope, pericardial rub

Pulmonary

Hemoptysia, tachypnea, rales,cyanosis, wheeze, pleural rub

Physical examination

Gastrointestinal

Hematemesis,hematochezia, melena, epigastric tenderness, organomegaly, trauma

musculoskeletal

Chest Trauma, chest bruising, chest asymmetry, chest localised swelling, chest localized tenderness, crepitus on palpation, arm limited range of motion

Other

Febrile, psychosis, suisidal ideation

Evaluation of chest pain

Medical history, cardiac examination

Abnormal history or cardiac examination

Normal history and cardiac examination

Yes

NO

Febrile, acute onset symptoms

Palpitation, chest pain, positive family history

Yes

NO

NO

Yes

Myocarditis,pericarditis Fever, rub, gallop, abnormal vital sign, ill appearance

Refer to pediatric cardiologist

At rest chest pain, exersional chest pain

Refer to pediatric cardiologist

Exertional chest pain

At rest chest pain or reproducible on exam

Suspected asthma

Low likehood of cardiac chest pain

Yes

NO

Reassurance

Bronchodilator

Refer to pediatric cardiologist

Improvement

Keeping management

Refer to pediatric cardiologist

Causes of sharp chest pain	Aspect
Ideopathic (73.6%)	The most common cause Duration:2-3 minutes Normal Chest-X-Ray (CXR), ECG findings
Respiratory (9.3%)	Asthma Acute bronchitis Pneumonia Pneumomediastinum Pneumothorax
Musculoskeletal (8.8%)	Chest wall tenderness Osteomyelitis of sternum
Cardiac (3.8%)	ASD Pulmonary artery stenosis VSD Aortic arch anomaly Large PDA with eisemenger Arrhythmia
Gastrointestinal (2.9%)	Gastritis GERD Acute gastroenteritis Dyspepsia
Psychiatric (1.4%)	Anxiety disorder Panic disorder

Red flag related cardiac etiology of chest pain

Cardiac origin
History of acquired or congenital cardiac disease
Exertional syncope
Exertional chest pain
Hypercoagulable state
Hypercholesterolemic state
Family history of sudden death under 35 years of age
Family history of premature coronary artery disease
Inheritted arrhythmia in the first relative
ICD implantation
Connective tissue disorders
Using cocaine,amphetamine

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

Do's

• Quickly evaluate cardiac examination in pediatrics presented with chest pain and syncope.
• Arrhythmia leading chest pain in children include: paroxysmal supraventricular tachycardia (PSVT), premature ventricular contraction (PVC), atrial flutter, mobitz type2 block ,atrial tachycardia, atrial premature contraction.
• Think about pneumothorax among young adult male presented with tachypnea, persistent pleuritic chest pain for 1-2 days and take a chest-X-ray for evaluation of air leak syndrome.
• If the CXR is undiagnostic for evaluation of pneumomediastinum, chest CT-scan is considered.

Don'ts

• The content in this section is in bullet points.