Chest pain resident survival guide (pediatrics)

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Resident
Survival
Guide

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

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 without finding any specifice underlying problem and the second cause is musculoskeletal. Although there are high worries among parents about the cardiac origin of chest pain in children, it consists in low percentage the 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.

Common Causes

[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]







Causes of sharp chest pain

Aspect

❑Ideopathic (73.6%)

❑ Normally otherwise

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 eisenmenger
Arrhythmia

Gastrointestinal (2.9%)

Gastritis
GERD
❑Acute gastroenteritis
Dyspepsia

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]


K02=
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
|}} K03=
Laboratory investigation in suspicion of musculoskeletal etiology:

Skeletal radiography
Spine CT scan
❑ Spine MRI
Nuclear bone scan
Creatine kinase with MM fraction
|}} K04=
Laboratory investigation for other etiology:

Viral, bacterial antibody level
Psychologic testing
Culture of blood, pericardial fluid, sputum
Urine, serum toxicology
Serum compelement level
❑Glycosylated Hb A1C
Hemoglobin electrophoresis
Cell blood count
Coagulation study
ESR
Mamography
Breast sonography
Breast biopsy
Thyroid function test
|}}
 
 
 
 
 
 
 
 
 
 
 
 
 
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
Tachypnea
Tachycardia
Rale
Wheeze
Gallop rhythm
Hematemesis
Hemoptysia
Melena
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
{{{ K02 }}}
 
{{{ K03 }}}
 
{{{ K04 }}}
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Complete Diagnostic Approach

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


 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 



 
 
 
 
Cardiac testing in pediatrics chest pain:
ECG
Echocardiography
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Febrile, acute onset symptoms
 
 
 
 
 
Palpitation, chest pain, positive family history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
NO
 
NO
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Psychologic
 
Cognitive behavior therapy
 
 
 
 
 
 

Do's

Don'ts

References

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