Chest pain resident survival guide (pediatrics)

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
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

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.

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 syndrome, acute pulmonary embolism, tamponade
• Abdominal aorta dissection with propagation to thoracic aorta
• Perforated peptic ulcer
• Air leak syndrome such as pneumothorax, pneumomediastinum

Common Causes

Common Causes of Chest pain in children include:

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

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

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

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

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 ❑ Hemoptysis ❑ 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

Laboratory investigation in suspicion of cardiac etiology: ❑ EKG ❑ CXR ❑ Echocardiography ❑ Holter monitoring ❑ Exercise stress test ❑ Dobutamin stress test ❑ Thalium scan ❑ Serum creatine kinase with MB fraction ❑ Serum troponin I ❑ Lipid profile ❑ Pericardiocenthesis ❑ Endomyocardial biopsy ❑ Catheterization

Laboratory investigation in suspicion of pulmonary etiology: ❑ CXR ❑ Chest CT scan ❑ Magnetic resonance imaging of the chest ❑ Pulmonary function test ❑ Bronchoscopy ❑ 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

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

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of pediatric chest pain.

Cardiac

Presence of 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

❑ ECG ❑ Abnormal physical exam, exertional chest pain, palpitation ❑ Suspected myocarditis, cardiomyopathy, pulmonary hypertension, pericarditis Echocardiography: ❑ Exertional chest pain, positive Family history ❑ Suspected abnormal coronary artery origin, myocarditis, pericarditis, cardiomyopathy, pulmonary hypertension, left ventricular outflow obstruction ❑ Troponin ❑ Suspected myocarditis, pericarditis, coronary ischemia Ambulatory ECG ❑ Chest pain , palpitation ❑ Suspected atrial arrhythmia,ventricular arrhythmia, intermittent heart block Exercise stress test ❑ Exertional chest pain, exertional syncope, palpitation ❑ Suspected coronary ischemia, exercise induced asthma

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

Reassurance

Yes

No

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.

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

• Quickly evaluate cardiac examination in children 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.
• Asthma is the most common cause of chest pain in the pulmonary group presenting with exertional chest pain.
• 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.
• In patients with chest pain and hypoxia, pulmonary embolism should be noticed.

• Acute chest syndrome or pulmonary infarction can be the manifestation of sickle cell disease among children.
• In patients presented with GERD or gastritis, chest pain is described as burning pain in epigastric area related to taking food.
• Hyperventilation in patients with panic disorder or anxiety disorder may lead to chest pain, paresthesia, dizziness, shortness of breath.
• Chest pain may be initial presentation of deformities in chest wall such as scoliosis due to nerve root compression.
• Mitral valve prolapse may be present with atypical chest pain in children.
• In case of marfan disease with sudden onset severe chest pain with radiation to the back, dissection aorta aneurysm should be evaluated.
• In patients with history of arterial switch in transposition of the great arteries (d-TGA), ostial coronary artery stenosis should be noticed.

• Homozygous familial hypercholesterolemia may lead to coronary artery disease and ischemic chest pain in the first two decades in children.

Don'ts

• Do not hesitate for urgent evaluation of patients presented with chest pain accompanied by dyspnea or unstable hemodynamic.