Chest pain in children: Difference between revisions

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Revision as of 18:59, 19 February 2021

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

Synonyms and keywords: Chest pain in kids

Overview

Historical Perspective

Chest pain in children is a common symptom and have a broad etiology. usually history and physical examination can determine the cause and help in differentiation of patients who require further investigations.

Classification

Chest pain in children can be classified to:

Cardiac
Non cardiac

Pathophysiology

The pathogenesis of chest pain differs according to the cause may be:
Inflammatory process in myocarditis, pericarditis, Kawasaki disease, Asthma, pneumona, esopahgitis and costocondritis.
Hypertrophy in hypertrophic cardiomyopathy.

Causes

Common causes of Chest pain in childern include:

Non Cardiac Causes:

Idiopathic

Musculoskeletal

Muscle strain
Trauma
Costochondritis
Precordial catch syndrome

Respiratory

Asthma
Pneumonia
Pneumothorax
Pulmonary embolism
Inhaled foreign body.
Chronic cough

Gastrointestinal

Gastroesophageal reflux( GERD)
Esophagitis
Gastritis
Foreign body

Miscellaneous

Psychogenic and Anexity
Sickle cell disease
Herpes zoster

Cardiac Causes:

Anomalous coronary arteries
Kawasaki disease
Dysrhythmias
Pericarditis
Myocarditis
Hypertrophic cardiomyopathy
Mitral valve prolapse
Aortic stenosis
Aortic aneurym

Epidemiology and Demographics

Patients with chest pain account for 650,000 visits annually in patients age group from10 to 21 years.
Patients with chest pain account for 5.2% of all cardiology consultations in inpatient and emergency department. and 15% of all outpatient visits.
Studies estimated only 0% to 5% of patients with chest pain have a cardiac etiology.

Natural History, Complications and Prognosis

The majority of patients with chest pain have bengin non cardiac causes.
Prognosis is generally good in non cardiac causes.

Diagnosis

Symptoms

Symptoms of chest pain may include the following:

Chest wall pain
Dyspnea
Cough
Heart burn
Pain after taking medications
Fever

Physical Examination

Physical examination may be reveals:

Chest wall tenderness in muscle strain and costochondritis
Murmur, gallop, pericardial friction rub, distant heart sounds, and abnormal second heart sound (loud S2)
Irregular rhythm,
Peripheral edema
Cyanosis
Tachypnea
Skin rash

Laboratory Findings

Cardiac troponin
CBC
CRP
ESR

Electrocardiogram

An ECG should be obtained if cardiac disease is suspected and when a noncardiac etiology is not clear.

ECG abnormalities can help with diagnosis:

Dysrrhythmia. However, in intermittent events the initial ECG will be normal.
Hypertrophic cardiomyopathy: left ventricular hypertrophy or strain.
Pericarditis: generalized ST segment elevation followed by T wave inversion.
Myocarditis: ST-T wave abnormalities.
Anomalous origin of the left coronary artery from the pulmonary artery: anterolateral infarction with deep and wide Q waves and T wave inversions in leads I, aVL, V5, and V6.
Pulmonary hypertension: signs of right ventricular hypertrophy and right axis deviation.
Pulmonary embolism: nonspecific ST-T segment changes or sinus tachycardia.

X-ray

An x-ray may be helpful in the diagnosis of the cause of chest pain.

x-ray may showes:

Cardiac enlargement in myocarditis and pericardial effusion
Prominent main and central pulmonary arteries. in pulmonary hypertension
infiltrates in pneumonia
atelectasis
Hyperinflation in asthma.
Pneumothorax, pneumomediastinum, or pleural effusions.
Radio-opaque esophageal foreign body (eg, button battery, or coin).

Echocardiography or Ultrasound

-Echocardiography may shows many incidental findings but also it can help in the diagnose of serious causes of chest pain, including hypertrophic cardiomyopathy, anomalous coronary artery origin, pericardial effusion, and pulmonary hypertension.

-Echocardiography is indicated in the patients with the following:

Exertional chest pain or syncope.
Chest pain associated with fever.
History of congenital heart disease, Kawasaki syndrome, or diseases that raise cardiac risk (eg, malignancy, hypercoagulable state).
Family history of cardiomyopathy, sudden death.
New murmur
Distant heart sounds
Pericardial friction rub
Loud S2
Peripheral edema
Abnormal electrocardiogram.

CT scan

CT scan may be helpful in the diagnosis of the cause of chest pain, including pulmonary embolism, aortic aneurysm and disection, and tumors.

MRI

MRI scan may be helpful in the diagnosis of the cause of chest pain, including myocarditis, Arrhythmogenic right ventricular dysplasia (ARVD) and tumors.

Other Diagnostic Studies

Holter monitoring to diagnosis arrhythmia as a cause of intermittent chest pain.

Treatment

Medical Therapy

The managment depend on the clinical status and stability of the patient, patients with sever respiratory distress, hemodynamic instability require rapid care of the (ABC) airway, breathing, and circulation according to the Pediatric Advanced Life Support (PALS).

The medical managment of stable patients differs according to the cause:

Costochondritis and ms strain can be treated with NSAIDs and muscle relaxants.
Infections like pneumonia can be treated with antibiotics, supplemental oxygen, and mechanical ventilation as needed
Gastritis and esophagitis can be treated with H2 blockers and PPIs.
Acute chest syndrome in sickle cell disease managed with pain control, broad spectrum antibiotics, hydration and blood transfusion, or exchange transfusion.
Pulmonary embolism requires anticoagulant therapy or, thrombolytics in hemodynamic unstable children.
Ischemia and myocardial infarction should receive anticoagulation, pain management, and catheterization.
Heart failure should managed with diuretics, ACEIs, and beta blocker if no contrindication.
Tachyarrhythmias should be managed according to Pediatric Advanced Life Support (PALS).
Pricarditis with pericardial effusion require pericardiocentesis in patients with tamponade.
Tumors require further work up and the managment differs according to the type of the tumor.

Surgery

Aortic root dissection managed with require emergent surgical intervention.
Tension pneumothorax requires needle or chest tube thoracostomy.
Airway foreign body with obstruction requires emergent securing of the airway and bronchoscopy.
Esophageal foreign body: management depends on the type of body. sharp foreign bodies, impacted batteries, or magnets requir urgent removal.

References

@@ Line 8: / Line 8: @@
 ==Historical Perspective==
-Chest pain in children is a common symptom and have a broad etiology.
+Chest pain in children is a common symptom and have a broad etiology.  usually history and physical examination can determine the cause and help in differentiation of patients who require further investigations.
 ==Classification==
 Chest pain in children can be classified to:
@@ Line 17: / Line 17: @@
 ==Pathophysiology==
-*The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3].
+*The pathogenesis of chest pain differs according to the cause may be:
-*The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
+*Inflammatory process in myocarditis, pericarditis, Kawasaki disease, Asthma, pneumona, esopahgitis and costocondritis.
-*On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
+*Hypertrophy in hypertrophic cardiomyopathy.
-*On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
+*
 ==Causes==
@@ Line 41: / Line 41: @@
 #Pneumonia
 #Pneumothorax
-#pulmonary embolism
+#Pulmonary embolism
-#inhaled foreign body.
+#Inhaled foreign body.
 #Chronic cough
@@ Line 79: / Line 79: @@
 *The majority of patients with chest pain have bengin non cardiac causes.
-*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
+*Prognosis is generally good in non cardiac causes.
-*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
-*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
-*Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
 ==Diagnosis==
-===Diagnostic Criteria===
-*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
-:*[criterion 1]
-:*[criterion 2]
-:*[criterion 3]
-:*[criterion 4]
 ===Symptoms===
+Symptoms of chest pain may include the following:
-*[Disease name] is usually asymptomatic.
+:*Chest wall pain
-*Symptoms of [disease name] may include the following:
+:*Dyspnea
+:*Cough
-:*[symptom 1]
+:*Heart burn
-:*[symptom 2]
+:*Pain after taking medications
-:*[symptom 3]
+:*Fever
-:*[symptom 4]
-:*[symptom 5]
-:*[symptom 6]
 ===Physical Examination===
-*Patients with [disease name] usually appear [general appearance].
+*Physical examination may be reveals:
-*Physical examination may be remarkable for:
-:*[finding 1]
+:*Chest wall tenderness in muscle strain and costochondritis
-:*[finding 2]
+:*Murmur, gallop, pericardial friction rub, distant heart sounds, and abnormal second heart sound (loud S2)
-:*[finding 3]
+:*Irregular rhythm,
-:*[finding 4]
+:*Peripheral edema
-:*[finding 5]
+:*Cyanosis
-:*[finding 6]
+:*Tachypnea
+:*Skin rash
 ===Laboratory Findings===
@@ Line 179: / Line 165: @@
 ==Treatment==
 ===Medical Therapy===
+The managment depend on the clinical status and stability of the patient, patients with sever respiratory distress, hemodynamic instability require rapid care of the (ABC) airway, breathing, and circulation according to the Pediatric Advanced Life Support (PALS).
-*There is no treatment for [disease name]; the mainstay of therapy is supportive care.
+The medical managment of stable patients differs according to the cause:
-*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
+*Costochondritis and ms strain can be treated with NSAIDs and muscle relaxants.
-*[Medical therapy 1] acts by [mechanism of action 1].
+*Infections like pneumonia can be treated with antibiotics, supplemental oxygen, and mechanical ventilation as needed
-*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].
+*Gastritis and esophagitis can be treated with H2 blockers and PPIs.
+*Acute chest syndrome in sickle cell disease managed with pain control, broad spectrum antibiotics, hydration and blood transfusion, or exchange transfusion.
+*Pulmonary embolism requires anticoagulant therapy or,  thrombolytics in hemodynamic unstable children.
+*Ischemia and myocardial infarction should receive anticoagulation, pain management, and catheterization.
+*Heart failure should managed with diuretics, ACEIs, and beta blocker if no contrindication.
+*Tachyarrhythmias should be managed according to Pediatric Advanced Life Support (PALS).
+*Pricarditis with pericardial effusion require pericardiocentesis in patients with tamponade.
+*Tumors require further work up and the managment differs according to the type of the tumor.
 ===Surgery===
-*Surgery is the mainstay of therapy for [disease name].
+*Aortic root dissection managed with require emergent surgical intervention.
-*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
+*Tension pneumothorax requires needle or chest tube thoracostomy.
-*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].
+*Airway foreign body with obstruction requires emergent securing of the airway and bronchoscopy.
+*Esophageal foreign body: management depends on the type of body. sharp foreign bodies, impacted batteries, or magnets requir urgent removal.
-===Prevention===
-*There are no primary preventive measures available for [disease name].
-*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
-*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].
 ==References==