RIME – Chest Pain Andrew Hughey, MSIII May 2011

History Intake

· Description of pain

o Onset: acute vs. chronic

o Quality: Sharp vs. dull, pain vs. “tightness/pressure”, “popping sensation”

o Location: Diffuse vs. localized, radiation (e.g. to the shoulder, jaw, or between the scapulas)

· Precipitating factors: Body position or movement, swallowing or eating, pleuritic, exertion

· Associated symptoms: Fever, dyspnea, vomiting or regurgitation, lightheadedness, paresthesias, syncope, palpitations

· Past Medical Hx: Asthma, cardiac disease, Kawasaki disease, sickle cell disease

· Family Hx: Marfan syndrome, Turner syndrome, type IV Ehlers-Danlos syndrome, hypertrophic cardiomyopathy

· Social Hx: Cocaine and tobacco use, use of other vasoactive drugs

Physical Exam

· Chest wall: Assess for tenderness and anterior slippage (click) of lower costal margin

· Pulmonary: Assess for tachypnea and respiratory distress, wheezing, diminished breath sounds

· Cardiovascular: Assess for murmur, pericardial friction rub, or an abnormal pulse or blood pressure

Diagnostic Studies

· CXR (if suspect pulmonary/cardiac), ECG / Holter monitor / echocardiogram / (if suspect cardiac), EGD / manometry / 42 hr pH testing (if suspect GI)

Differential Diagnosis

	Musculoskeletal (15-31%)	Psychological (0-30%)	Respiratory (2-11%)	Cardiac * (2-8%)	Miscellaneous
Causes	Costochondritis, trauma / contusion, slipping rib syndrome	Anxiety, conversion disorder	Asthma, severe cough, pneumonia, pneumothorax / pneumomediastinum, pulmonary embolism	CAD (ischemia/infarction, Kawasaki disease), arrhythmia, HOCM, pulmonic stenosis, MVP, pericarditis, myocarditis	- IDIOPATHIC (21-45%) - GI causes (2-8%): GERD, gastritis, esophageal dysmotility - Breast tenderness (puberty) - Vaso-occlusive crisis or acute chest syndrome (sickle cell disease) - Aortic dissection (Marfan syndrome - Pleural effusions (vascular collagen diseases) - Shingles
Signs & Symptoms	- Hx of direct trauma or strain (wrestling, carrying heavy books, exercising) - Chest tenderness or pain with movement of the torso or upper extremities	- Stressful events (e.g. recent death, illness or accident in the family, family separations, school changes) - Other recurrent somatic complaints (e.g. headache, abdominal or extremity pain) - Lightheadedness or paresthesias secondary to hyperventilation	- Pain induced by exercise (may suggest asthma) - Accompanied by other symptoms of URI (cough, congestion, coryza) - Tachypnea, respiratory distress - Wheezing heard on auscultation - Diminished breath sounds suggestive of consolidation - Fever, elevated WBC suggestive of infection - CXR demonstrating pneumonia - Decreased peak flow (asthma)	- Pain with exertion, palpitations, or syncope - Presence of predisposing conditions: diabetes, Kawasaki disease, chronic anemia, cocaine - Murmur, pericardial friction rub, or an abnormal pulse or blood pressure - Cardiomegaly on CXR - Arrhythmia on ECG - Structural abnormality on echocardiogram
Diagnosis	- Clinical diagnosis - Other causes reasonably ruled out	- Clinical diagnosis - Other causes reasonably ruled out	- Clinical diagnosis based on history, objective findings, and response to therapy (e.g. albuterol trial)	- Referral to pediatric cardiologist - ECG/Holter, echocardiogram
Treatment	- Rest - Analgesics - Cortisone injections (for refractory costochondritis)	- Reassurance - Additional counseling or psychiatric referral as needed	Depends on etiology: - Asthma: β-agonist, inhaled corticosteroids - Pneumonia: antibiotics - Viral URI: Symptomatic support	Treat underlying cause: - Surgery (if anatomical) - β-blockers - Pacemaker/ICD

* Cardiac causes of chest pain are uncommon in children; patients with anginal pain, pain with exertion not attributed to respiratory disease, palpitations, or syncope should be referred to a pediatric cardiologist for further evaluation.

Abbreviations:

‘Hx’ = history; ‘CXR’ = chest x-ray; ‘ECG’ = electrocardiogram; ‘EGD’ = esophagogastroduodenoscopy; ‘GI’ = gastroenterological;

‘URI’ = upper respiratory infection; ‘WBC’ = white blood cell; ‘CAD’ = coronary artery disease; ‘HOCM’ = hypertrophic cardiomyopathy;

‘MVP’ = mitral valve prolapsed; ‘ICD’ = implantable cardioverter-defibrillator; ‘GERD’ = gastroesophageal reflux disease

Sources:

Geggel RL et al. “Approach to chest pain in children.” Uptodate.com. Accessed May 2011.

Nelson Textbook of Pediatrics 17^th ed.

Selbst SM. “Consultation with the specialist. Chest pain in children.” Pediatr Rev. 1997 May;18(5):169-73.