Evaluation of Chest Pain in the Pediatric Patient
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Transcript Evaluation of Chest Pain in the Pediatric Patient
Jennifer Thull Thull-Freedman, MD, MSCI, FAAP(PEM)
Assistant Professor of Paediatrics
University of Toronto
Co Co-director, PEM Clinical Fellowship
The Hospital for Sick Children
From my residency
A 12-year year-old previously healthy boy presented to
the ED after first seeking care at the neighborhood fire
department for chest pain
Told to take a warm bath for muscle aches
Arrived several hours later alert but in pain
HR=130, BP not done
CXR obtained
Child waited in room for CXR to be reviewed
From my residency
Child suddenly became unresponsive and pulseless
Unable to be resuscitated
CXR reviewed during resuscitation showed
widened mediastinum
Autopsy revealed dissection of the aorta
However
Most cases of chest pain in children are not related to
serious pathology
History and physical exam often sufficient evaluation
The challenge
Objectives
Review relevant literature
Review common causes of chest pain in children
Discuss uncommon but serious causes
Present an approach to the child with chest pain
Summarize take take-home points
Etiology of chest pain in kids
Very few studies
Most retrospective
Variable inclusion/exclusion criteria
Limited detail provided
Selbst et al
Objectives:
Identify causes of chest pain in children
Assess value of echocardiogram
Prospective
Enrolled all patients with chest pain
ECG and echo offered to those with ill ill-defined or
suspected cardiac etiology
PediatricsPediatrics1988; 82: 3191988; 319--323323
Selbst et al.
Population
407 patients
Philadelphia, Pennsylvania
Median age 12.5 years
55% female, 90% African African-American
43% acute pain <48 hours
Did not exclude known disease
PediatricsPediatrics1988; 82: 3191988; 319--323323
Selbst et al.
ECG ECG’s in 191/235 children
31 abnormal (16%)
27 minor or previously known findings
3 dysrhythmias detected on physical exam
1 with known SLE had findings of pericarditis
PediatricsPediatrics1988; 82: 3191988; 319--323323
Selbst et al.
Echocardiograms in 139/235
17 abnormal (12%)
12 mitral valve prolapse (8.6%)
Similar prevalence to general population
2 pericardial effusion
2 mitral valve regurgitation
1 poor LV function
PediatricsPediatrics1988; 82: 3191988; 319--323323
Selbst et al.
Chest radiographs in 137/407
37 abnormal (27%)
Most frequent: infiltrates, atelectasis, hyperinflation
1 pneumothorax in a child with Marfan Marfan’s
syndrome
1 clavicle fracture suspected clinically
1 child with SLE had pleural effusion, large heart
PediatricsPediatrics1988; 82: 3191988; 319--323323
Selbst et al.
Organic disease related to
Age <12 years
Pain awakening child from sleep
Acute onset
Abnormal physical exam
Not related to description or location of pain
PediatricsPediatrics1988; 82: 3191988; 319--323323
Selbst et al. #2
6-month follow follow-up of 149/407 patients
43% had intermittent or persistent pain
No significant disease identified
1 mitral valve prolapse
1 gastrointestinal disease
3 asthma
Conclusion:
H&P sufficient for identifying majority of significant
etiologies
Clinical PedsPeds1990; 29: 3741990; 374--77
Rowe et al.
Chest X X-rays done in 50%
18/161 with positive result
15 infiltrates
2 pneumomediastinum
1 pneumothorax
ECG done in 18%
2/60 with significant new findings
Tachycardia and ST changes suggested myocarditis
WPW
CMAJCMAJ1990; 143:3881990; 388--9494
Massin et al.
9 cases cardiac etiology in 168 PED patients
3 SVT
2 MVP
4 sick sinus
1 myocarditis
1 pericarditis
1 cardiac hemochromatosis with β-thalassemia
5 cases cardiac etiology in 69 card. clinic patients
5 SVT
Clin Pediatr 2004;43:231 231
Massin et al.
Results
Palpitations or abnormal auscultation predicted all
cases of cardiac disease
Conclusions
Chest pain in children usually benign
History and physical usually sufficient
Laboratory testing guided by H&P
Clin Pediatr 2004;43:231 231-
Limitations of current literature
Small numbers for characterizing rare events
Limited detail
Children with known disease not excluded
Lack of follow follow-up
No evidence evidence-based guidelines
Differential Diagnosis
Chest wall
Gastroesophageal
Reflux
Foreign body
Pulmonary
Trauma
Costochondritis
Precordial catch
Slipping rib
Infection
Mastalgia
Zoster
Asthma
Pneumonia/effusion
Pneumothorax
Pleurisy
Pulmonary embolus
Malignancy
Hematologic
Sickle cell disease
Psychogenic
Differential Diagnosis
Cardiac
Angina
Coronary abnormalities
Hypercoagulable state
Cocaine
Obstructive heart disease
IHSS, aortic stenosis
Pericardial effusion/pericarditis
Arrhythmias
Myocarditis
Aortic aneurysm
Cases
Case
A 12-year year-old girl presents to the emergency
department with chest pain for 2 days
Started gradually
Worse with deep breath
Had URTI last week
Afebrile
Tender on both sides of sternum
Remainder of physical exam normal
Costochondritis
Inflammation of costochondral cartilage
Cause
Overuse
Preceding URTI with cough
Idiopathic
Sharp pain, worse with movement
All ages
Tenderness over costochondral joints
Case
A 10 10-year year-old boy presents to the ED with
recurrent episodes of left chest pain.
Feels like a sudden stab
Can’t take a deep breath
Lasts 2 2-3 minutes
Occurs at rest
Not reproducible
Normal physical exam
Precordial Catch Syndrome
“Texidor’s twinge”
Sudden, brief
Occurs at rest
Localized
Sharp
Exacerbated by deep breath
No associated symptoms
No physical findings
Case
A 6 6-year year-old girl comes to the emergency
department after having chest pain at home.
Stopped playing, became clingy, said chest hurt
Mom thought she looked pale
Now looks and feels better
HR=110, normal physical exam
SVT
In children >1 year
82% present with palpitations
14% with pain
14% perspiration
14% dizzy
4% pallor
1-3% of chest pain complaints in ED
6% of chest pain referred to cardiologist
Median time from symptoms to diagnosis 138d
Case
A 13 13-year year-old boy presents to the emergency
department with sudden severe chest pain
Sharp pain in anterior chest
Appears anxious
BP 80/40 in right arm
Diastolic murmur
Marfan syndrome
Caused by fibrillin gene mutation
Manifestations
Musculoskeletal: Tall, long limbs and fingers, pectus
Ocular: Lens dislocation
Cardiovascular: Aortic root dilation, MVP
Pulmonary: Spontaneous pneumothorax
50% have aortic root dilation by age 10 years
90% have aortic root dilation by age 20 years
Aortic dissection
Children at risk
Marfan syndrome
Ehlers-Danlos
Coarctation
Aortic stenosis
Turner syndrome
Endocarditis
Cocaine use
Case
A 17-year year-old female presents to the ED with chest
pain that has lasted for 1 hour
Pain began during soccer practice
Has happened previously with exercise
Midsternal, squeezing, radiates to left arm
PMH: Admitted to hospital for FUO at age 2 years
Kawasaki Disease
Acute febrile vasculitis of childhood
Features
Fever (>39 degrees for 5 days)
Non Non-exudative conjunctivitis
Erythema of oral mucosa and tongue
Erythema and swelling of hands and feet
Cervical adenitis >1.5 cm
Rash
Leading cause of acquired heart disease in kids
Cardiac sequelae of KD
Acute and subacute
Myocarditis (50% of patients)
Pericarditis
Mitral, aortic insufficiency
Arrhythmias
Coronary aneurysms
20 20-25% if untreated
5% if treated with IVIG
Appear 7 days to 4 weeks after onset of fever
Cardiac sequelae of KD
Long-term follow follow-up (> 10 years) of 594
untreated patients
IVIG treatment standard since late 1980 1980’s
24.6% had coronary aneurysms
49% had regression
19% developed stenosis (4% of total)
8% developed myocardial infarction (2% of total)
Circulation1996;94:1379-85
Myocardial ischemia in kids
Anomalous coronary arteries
Prevalence 2:1000
Anomalous origin of L coronary from pulm. Artery
Presents in first months of life
Irritability, heart failure, cardiac enlargement
Anomalous origin from incorrect sinus of Valsalva
Presents later in childhood
Compression between aorta and pulm Artery
Hypoplastic coronary arteries
Myocardial ischemia in kids
Sickle cell disease
Myocardial infarction uncommon but described
Perfusion defects in 5% children studied in a Paris sickle
cell clinic ( Arch Dis Child 2004;89:359 359-62)
Microvascular occlusion of small vessels
Exchange transfusion may be helpful for acute ischemia
( Pediatrics 2003;111:e183 e183-7)
Myocardial ischemia in kids
Nephrotic syndrome
Thrombotic occlusion of coronary arteries
Long Long-standing diabetes mellitus
Familial hypercholesterolemia
SLE, Antiphospholipid antibody syndromes
Cardiac transplant
Cocaine abuse
Case
A 16-year year-old boy presents to the emergency
department after fainting at a track meet
Remembers having chest pain during his race
Father died suddenly in his 30 30’s
Systolic murmur on exam
Hypertrophic cardiomyopathy
Autosomal dominant
Symptoms in 2 2nd nd decade
May present with angina angina-like pain or syncope
Impaired diastolic relaxation, increased O O2 demand
Risk of sudden death 6% in children
Hypertrophic cardiomyopathy
Case
A 6-year year-old girl presents to the ED with cough
for 3 weeks and chest pain for 1 week
Feels very tired
Illness began with URTI 3 weeks ago
Afebrile
Heart rate = 160
Liver palpable 3 cm below RCM
Myocarditis
Usually viral etiology
Enterovirus (coxsackie), adenovirus
Presentation
Heart failure
Chest pain
More likely in older kids and adults
Ischemia or concurrent pericarditis
Myocarditis
Physical findings
Tachycardia, tachypnea
Poor perfusion
Muffled heart sounds, S3, murmur
Hepatomegaly
CXR
Cardiomegaly
Pulmonary edema
Myocarditis
ECG
Sinus tachycardia
Decreased voltages (<5 mm) limb leads
LVH
Prolonged PR interval, prolonged QT interval
Echocardiogram
Hypokinesis, impaired function
Hypertrophic cardiomyopathy
Case
A 6-year year-old girl presents to the ED with cough
for 3 weeks and chest pain for 1 week
Feels very tired
Illness began with URTI 3 weeks ago
Afebrile
Heart rate = 160
Liver palpable 3 cm below RCM
Pericarditis
Infectious etiology common in children
Pain
More common in older children and adolescents
Worse when supine, relieved by leaning forward
Physical findings
Friction rub if effusion small
Muffled heart sounds, pulsus paradoxus if large
Pericarditis
ECG
Low voltages
ST elevation
Usually leads I, II, V5, V6
Electric alternans
Produced by swinging motion of heart within effusion
Case
A 9-year year-old obese boy is brought to the ED at
11 pm complaining of chest pain since dinner preventing
him from sleeping
Has been having episodes for few weeks
Described as burning
Worse after big meals and when lying down
Normal physical exam
Gastroesophageal Reflux
Berezin et al.
27 children 8 8-20 years with idiopathic chest pain all
received EGD, manometry, pH monitoring
Not blinded, no control group
Results: 78% had gastroesophageal cause
16 of 27 (59%) had esophagitis
4 of 27 (15%) had gastritis
1 of 27 (4%) with abnormal manometry
Gastroesophageal Reflux
Accounts for 5 5-10% of PED chest pain visits
Classic pain is temporally associated with meals
Burning, retrosternal
Trial of antacid, H2RA, PPI is appropriate
Consider pH probe if diagnostic testing needed
Case
A 3 3-year year-old boy is evaluated in the emergency
department with chest pain for several hours
Points to sternal notch
Drooling
Refusing juice
Afebrile, well well-appearing
Breath sounds equal
Esophageal foreign body
Case
An 8 8-year year-old boy is brought to the ED directly
from a hockey practice during which he said his chest
hurt and he couldn couldn’t breathe
Several similar episodes
Feeling better since arrival to ED
Tight cough
Normal breath sounds, no murmur
Normal CXR and EKG
Asthma
May account for 10 10-20% chest pain in kids
Personal or family history atopic conditions
Associated with cough
May be worse at night or with exercise
Wheezing not always detectable
Trial of bronchodilator
Consider PFT for pain with exercise
Case
A 17 17-year year-old boy presents to the emergency
department with right chest pain
Just returned hours ago from vacation in Cozumel
Pain began one day ago
Progressive dyspnea during flight home
Pneumothorax/pneumomediastinum
Children at risk
Asthma, bronchiolitis
Barotrauma
Cough, choking, vomiting
Crack, cannabis
Cystic fibrosis
Marfan syndrome
Tall male teenagers
Case
A 15-year year-old girl presents to the ED with chest
pain
Present for several days
Reports feeling dizzy and short of breath
Not associated with exercise
Physical exam unremarkable
Grandmother died last week of heart attack
Psychogenic
Psychogenic
5-20% of chest pain in children
More common in adolescents
Recent or current stressful situation
Family illness, especially cardiovascular
Family history of chest pain
Other somatic and sleep complaints
Depression
The approach: History
Description of pain
Not as reliable in children as in adults
Precipitating factors
Exertion
Eating
Deep breathing
Muscle use
Trauma
Emotional stress
The approach: History
Frequency and chronicity
Associated symptoms
Fever
Cough
Shortness of breath
Syncope
Dizziness
Palpitations
The approach: History
The approach: History
Past medical history
Known heart disease
Asthma or atopic conditions
Prothrombotic conditions
Cancer
SLE
Nephrotic syndrome
Medications and drugs
Family history
The approach: Physical exam
General appearance
Body habitus
Vital signs
Chest wall palpation
Auscultation
Abdomen
Peripheral perfusion
Red flags
Pain associated with exercise, palpitations, or syncope
Shortness of breath
Pain limits daily activities or disturbs sleep
Substance abuse
Presence of prothrombotic conditions
PMH consistent with Kawasaki disease
Family history of sudden death or early cardiac death
Abnormal vital signs or physical findings
The approach
Further evaluation
CXR
ECG
Holter monitor
Echocardiogram
Cardiology consultation
Therapeutic trials
Summary
Chest pain in pediatrics usually due to benign,
identifiable etiology
Cardiac and other life life-threatening causes of
chest pain rare but do exist
Often can be ruled out by history and physical exam
Diagnostic tests appropriate in presence of red flags