Originally published at Pediatric EM Morsels on May 15, 2015. Reposted with permission.

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Children like to pretend to be grown-ups.  Unfortunately, sometimes they develop grown-up problems (Cholelithiasis, Kidney Stones, and Hypertension).  Additionally, often kids will complain of symptoms that warrant great concern in adults, but often engender apathy when considered in children. Chest Pain is a great example of one of these complaints.

Chest Pain: Hysteria vs Vigilance

• The odds are in favor of being reasonable
  • Only ~1-6% of chest pain in children is due to a cardiac cause
  • GI cause – 2-11% of chest pain
  • Musculoskeletal – 2-11% of chest pain
  • No Identifiable cause – 21-45% of the time!
• Yet, our job requires vigilance for find the rare dangers!

Culprits to Consider

• Cardiac
  • Hypertrophic Cardiomyopathy
    • ECG abnormal in 95% of cases
    • Left Axis Deviation
    • Large Voltages
    • Deep, narrow Q waves in lateral leads
    • Deep, narrow T wave inversions in lateral leads
  • Dysrhythmias
    • Look specifically for:
      • Prolonged QTc, Short PR, delta waves, evidence of HOCM, ST Elevations, symmetric TWI, AV Blocks, Brugada Sign.
  • Pericarditis
  • Myocarditis
  • Ischemia
• Pulmonary
  • Pneumothorax
  • Pneumomediastinum
  • Asthma
  • Pneumonia
  • Pulmonary Embolism
  • Aspirated Foreign Body
• Heme
  • Sickle Cell Disease
• Chest Wall
  • Herpes Zoster
  • Trauma
  • Costocondritis

Chest Pain: Evaluation

• The goal is to balance risk of the rare with risk of over-testing.
• Reasonable screen for cardiac etiology [Kane, 2010]:
  • Chest Pain with Exertion?
  • High-risk family history (ex, unexplained sudden death)?
  • Abnormal exam (ex, murmurs, hepatomegaly)?
  • Abnormal ECG
• Reasonable screen for pulmonary etiology:
  • CXR
    • Obviously useful… but perhaps leads to unnecessary imaging.
  • If pneumothorax is your primary concern, consider the Bedside Ultrasound
    • There are plenty of studies  that demonstrate that U/S is more sensitive than supine CXR in the setting of adult trauma.
      • U/S – ~90% sensitive
      • Supine CXR – ~50% sensitive
      • Erect CXR has increased sensitivity (~90%), naturally.
    • U/S is naturally operator dependent… and in this case the operator is you… so are you dependable?
      • This is a quick basic review of thoracic ultrasound.
      • Look here for a quick demonstration by Dr. Tony Weekes.

Moral of the Morsel

• For the young patient presenting with chest pain, be vigilant, but be reasonable.
• Screen for badness with:
  • Thorough history and directed physical exam
  • ECG
  • Ultrasound and/or CXR.

References