Paediatric Acute care Guidelines PMH Emergency Department

Background

  • There are many causes of chest pain in children, but less than 5% are due to cardiac or other life threatening disease.
  • In adolescents, most presentations with chest pain are psychosomatic or no cause is found.
  • Management is related to the underlying cause. 
 

Assessment

Could there be a Cardiac Cause?

Symptoms & Signs for Cardiac Disease

  • First episode of pain
  • Pain radiating to arm or back
  • Associated dizziness or collapse
  • History of cardiac, clotting, connective tissue or Kawasaki’s disease
  • Long standing diabetes mellitus
  • Cocaine or other stimulant use
  • Abnormal pulse or blood pressure

Congenital Heart Disease

  • Can directly cause pain but more often causes arrhythmias or heart failure

Ischaemic  Heart Disease

  • Presentation is similar to adult angina

Pericarditis

  • Pain relieved on sitting forward
  • Widespread “saddle-shaped” ST elevation on ECG

Myocarditis

  • Usually after a viral illness
  • Suspect if there is a history of dizziness/collapse or if there is a tachycardia that does not respond to fluid boluses
  • The CXR and ECG may be normal or have only non specific changes but cardiac enzymes are usually elevated

Endocarditis

  • Consider if there is fever with a new murmur , but remember innocent flow murmurs are more common

Aortic Dissection

  • Patients with connective tissue diseases or congenital aortic root abnormalities are at risk
  • The typical pain is “tearing” and radiates to the back
  • There may be a difference between blood pressure in each arm
  • As this is a dissection not an aneurysm, the mediastinum may not be wide on CXR

Could this be a Pulmonary Embolus?

Risk Factors for Pulmonary Embolus

  • Immobility or recent surgery
  • Neoplasm
  • Hypercoaguability
  • Central venous catheter
  • Pleuritic pain
  • Haemoptysis
  • Hypoxia
  • The most frequent symptoms are pleuritic pain, dyspnoea, apprehension, cough and haemoptysis
  • The most frequent signs are tachypnoea and tachycardia

Can another Specific Diagnosis be Made?

Respiratory

Pneumothorax

  • Classically occurs in young thin adolescents after coughing or a Valsalva manoeuvre

Acute chest syndrome

  • Consider if there is cough, fever in a patient with sickle cell disease

Exercise induced asthma

  • There are usually other features of asthma present

Foreign Body

  • Consider if history of choking episode, colour change, persistent wheeze of unilateral signs

Pneumonia/Pleurisy

  • Associate fever, cough, crackles, consolidation

Musculoskeletal causes

  • The hallmark of musculoskeletal pain is well-localised pain that can be reproduced with a simple movement (not exercise), inspiration or palpation
  • An association with trauma or overuse may not always be obvious

Slipping rib syndrome

  • Ribs 8 to 10 (which are not directly attached to the sternum) may slip superiorly to impinge on intercostal nerves
  • There is often a sharp pain followed by a dull ache
  • Pain may be reproduced by a “hooking manoeuvre” – pulling the lower rib edge superiorly and anteriorly

Costochondritis

  • Costochondral joints become painful and tender
  • Intercostal muscle strain

Precordial catch

  • Classically, several seconds of severe chest and back pain occur, often when moving form slouching posture 

 

  • Treatment of musculoskeletal causes involves a reassurance, rest, and simple analgesia or non-steroidal anti inflammatory medications
  • Athletes with recurrent overuse injuries may benefit from a sports medicine referral

Gastrointestinal Causes

Gastroesophageal reflux

  • Exacerbated by food or lying flat (often on going to bed)

Ingested foreign body 

Miscellaneous Causes

Breast tenderness

  • Related to hormonal changes at puberty or with pregnancy

Shingles (pre rash)

 

Trauma

Is There A Serious Underlying Psychiatric Cause?

  • In some studies, up to 10% of adolescents with chest pain may have a serious underlying psychiatric cause
  • Most presentations with chest pain are psychosomatic or no cause found

Risk Factors for Serious Psychiatric Disease

  • Lowered affect or lack of motivation
  • Hypervigilance
  • Hyperventilation
  • Social withdrawal
  • Impairment of function at school

Depression

  • Look for irritability, lack of motivation and alteration of appetite or sleep pattern

Panic Attacks

 

Somatoform Disorders

  • Rare cases where excessive concern about chronic symptoms causes significant functional impairment

Features Suggesting Psychosomatic Pain

  • Vague symptoms of varying nature, intensity and pattern
  • Multiple symptoms at the same time
  • Chronic, intermittent course with apparently good health
  • Exacerbation by stress

The Emergency department approach to patients with psychosomatic chest pain is to:

  • Reassure that serious illness is unlikely and no further investigations are needed
  • Relaxation and stress relief should be encouraged
  • Refer to General or Adolescent Paediatric Teams – as symptoms persist in one third, and the level of symptomatology and functional distress often increase
  • Reconsider organic illness if patients present with new symptoms 

References

PMH ED Guidelines:  Chest Pain – Last updated October 2014

Tags

We want your feedback!

Help us provide guidelines that are useful to you, the clinician.

Give feedback here