Chest pain resident survival guide (pediatrics)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sara Zand, M.D.[2]

Chest pain resident survival guide (pediatrics) Microchapters


Chest pain is the second common cardiac symptom after cardiac murmur referred to a pediatric cardiologist for evaluation. The most common cause of chest pain in children is idiopathic without finding any specific underlying pathology and the second cause is musculoskeletal. Although there are high worries among parents about the cardiac origin of chest pain, it consists in low percentage cause of pediatric chest pain. Evaluation of chest pain includes assessments of respiratory system, gastrointestinal system, cardiovascular system and psychologic factors.


Life Threatening Causes

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

Common Causes

Common Causes of Chest pain in children include:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]

Causes of sharp chest pain


❑ Ideopathic (73.6%)

❑ Normally otherwise

Respiratory (9.3%)

Acute bronchitis

Musculoskeletal (8.8%)

Chest wall tenderness
Osteomyelitis of sternum

Cardiac (3.8%)

Pulmonary artery stenosis
Aortic arch anomaly
❑ Large PDA with eisenmenger

Gastrointestinal (2.9%)

❑ Acute gastroenteritis

Psychiatric (1.4%)

Anxiety disorder
Panic disorder

Causes of pediatric chest pain
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

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[19][20][21][22]

Psychogenic origin, School problem, family troubles (parents divorce)
Gastrointestinal origin, chest pain associated with indigestion, heart burn, vomiting,
Cardiac origin, Congenital heart disease, kawasaki, arrhythmia
Ideopathic, No evidence of any organic etiology or any psychologic factors
Characteristics of chest pain
Squeezing, sharp, dull, duration of chest pain
Musculoskeletal origin, chest wall tenderness,Pain aggravated with inspiration,Muscle pain with movement,Tenderness on palpation of costochondral junction
Respiratory related,Chest pain secondary to acute onset of cough,wheezing, asthma
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%)
Physical examination
Gallop rhythm
Is there any red flag about cardiac etiology?:

❑ History of acquired or congenital cardiac disease
❑ Exertional syncope
❑ Exertional chest pain
Hypercoagulable state
Hypercholesterolemia 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 disease
❑ Using cocaine, amphetamine
Laboratory investigation in suspicion of pulmonary etiology:

Chest CT scan
Magnetic resonance imaging of the chest
Pulmonary function test
Ventilation perfusion scan
Sweat test
Laboratory investigation in suspicion of gastrointestinal etiology:

Gastric lavage
PH probe
Upper GI series
Upper endoscopy
Abdominal sonography
Liver function test
Lipase, amylase
Serum gastrin level
Stool guaic testing
Laboratory investigation in suspicion of musculoskeletal etiology:

Skeletal radiography
Spine CT scan
❑ Spine MRI
Nuclear bone scan
Creatine kinase with MM fraction

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of pediatric chest pain.[1][23][24]

Presence of underlying congenital or acquired heart disease, arrhythmia, crushing chest pain, exercised induced chest pain, persistent tachycardia, hypotension, gallop rhythm, syncope, pericardial rub
Hemoptysia, tachypnea, rales,cyanosis, wheeze, pleural rub
Physical examination
Hematemesis,hematochezia, melena, epigastric tenderness, organomegaly, trauma
Chest Trauma, chest bruising, chest asymmetry, chest localised swelling, chest localized tenderness, crepitus on palpation, arm limited range of motion
Febrile, psychosis, suisidal ideation

Cardiac testing in pediatrics chest pain:
Troponin test
Ambulatory ECG
Exercise stress test
Evaluation of chest pain
Medical history, cardiac examination
Abnormal history or cardiac examination
Normal history and cardiac examination
Febrile, acute onset symptoms
Palpitation, chest pain, positive family history
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
Refer to pediatric cardiologist
Keeping management
Refer to pediatric cardiologist


Shown below is an algorithm summarizing the treatment of chest pain in children.[25]

Cardiac causes such as IHD, pericarditis, tamponade, arrhythmia
Treatment of underlying causes
Musculoskeletal origin
Reassurance, rest,analgesic, anti-inflammatory agent (NSAID), warm compression
Treatment of pediatric chest pain
Pulmonary disease ( bronchitis, asthma, pleurisy, pleural effusion, pneumonia, empyema, bronchiectasis, lung abscess),
antibiotic therapy, bronchodilator therapy,pleural fluid derenage, chest tube insertion
Gastrointestinal disorder ( GERD, gastritis, cholecystitis, PUD)
Antacid, H.pilory eradication, antibiotic therapy, surgery
Cognitive behavior therapy




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