Pediatric Chest Pain

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

Follow Dr. Sean M. Fox on twitter @PedEMMorsels

Chest-Pain-2

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

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?

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

Angoff GH1, Kane DA, Giddins N, Paris YM, Moran AM, Tantengco V, Rotondo KM, Arnold L, Toro-Salazar OH, Gauthier NS, Kanevsky E, Renaud A, Geggel RL, Brown DW, Fulton DR. Regional implementation of a pediatric cardiology chest pain guideline using SCAMPs methodology. Pediatrics. 2013 Oct;132(4):e1010-7. PMID: 24019419.[PubMed] [Read by QxMD]

Friedman KG1, Kane DA, Rathod RH, Renaud A, Farias M, Geggel R, Fulton DR, Lock JE, Saleeb SF. Management of pediatric chest pain using a standardized assessment and management plan. Pediatrics. 2011 Aug;128(2):239-45. PMID: 21746719. [PubMed][Read by QxMD]

Kane DA1, Fulton DR, Saleeb S, Zhou J, Lock JE, Geggel RL. Needles in hay: chest pain as the presenting symptom in children with serious underlying cardiac pathology.Congenit Heart Dis. 2010 Jul-Aug;5(4):366-73. PMID: 20653703. [PubMed] [Read by QxMD]

Son MB1, Sundel RP. Musculoskeletal causes of pediatric chest pain. Pediatr Clin North Am. 2010 Dec;57(6):1385-95. PMID: 21111123. [PubMed] [Read by QxMD]

Selbst SM1. Approach to the child with chest pain. Pediatr Clin North Am. 2010 Dec;57(6):1221-34. PMID: 21111115. [PubMed] [Read by QxMD]

Lichtenstein DA1, Mezière G, Lascols N, Biderman P, Courret JP, Gepner A, Goldstein I, Tenoudji-Cohen M. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005 Jun;33(6):1231-8. PMID: 15942336. [PubMed] [Read by QxMD]

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