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Evaluation of Chest Pain in the Pediatric Patient

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 .

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Evaluation of Chest Pain in the Pediatric Patient

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  1. Evaluation of Chest Painin 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

  2. 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

  3. 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

  4. However • Most cases of chest pain in children are not related to serious pathology • History and physical exam often sufficient evaluation

  5. The challengeObjectives • 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

  6. Etiology of chest pain in kids • Very few studies • Most retrospective • Variable inclusion/exclusion criteria • Limited detail provided

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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 ClinPediatr2004;43:231 231

  16. 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-

  17. 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

  18. Differential Diagnosis • Chest wall • Trauma • Costochondritis • Precordialcatch • Slipping rib • Infection • Mastalgia • Zoster • Gastroesophageal • Reflux • Foreign body • Pulmonary • Asthma • Pneumonia/effusion • Pneumothorax • Pleurisy • Pulmonary embolus • Malignancy • Hematologic • Sickle cell disease • Psychogenic

  19. Differential Diagnosis • Cardiac • Angina • Coronary abnormalities • Hypercoagulablestate • Cocaine • Obstructive heart disease • IHSS, aortic stenosis • Pericardial effusion/pericarditis • Arrhythmias • Myocarditis • Aortic aneurysm

  20. 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

  21. Costochondritis • Inflammation of costochondral cartilage • Cause • Overuse • Preceding URTI with cough • Idiopathic • Sharp pain, worse with movement • All ages • Tenderness over costochondral joints

  22. 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

  23. Precordial Catch Syndrome • “Texidor’s twinge” • Sudden, brief • Occurs at rest • Localized • Sharp • Exacerbated by deep breath • No associated symptoms • No physical findings

  24. 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

  25. 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

  26. 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

  27. 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

  28. Aortic dissection • Children at risk • Marfan syndrome • Ehlers-Danlos • Coarctation • Aortic stenosis • Turner syndrome • Endocarditis • Cocaine use

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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)

  35. 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

  36. 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

  37. 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

  38. 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

  39. Myocarditis • Usually viral etiology • Enterovirus (coxsackie), adenovirus • Presentation • Heart failure • Chest pain • More likely in older kids and adults • Ischemia or concurrent pericarditis

  40. Myocarditis • Physical findings • Tachycardia, tachypnea • Poor perfusion • Muffled heart sounds, S3, murmur • Hepatomegaly • CXR • Cardiomegaly • Pulmonary edema

  41. Myocarditis • ECG • Sinus tachycardia • Decreased voltages (<5 mm) limb leads • LVH • Prolonged PR interval, prolonged QT interval • Echocardiogram • Hypokinesis, impaired function

  42. 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

  43. 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

  44. Pericarditis • ECG • Low voltages • ST elevation • Usually leads I, II, V5, V6 • Electric alternans • Produced by swinging motion of heart within effusion

  45. 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

  46. 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

  47. 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

  48. 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

  49. 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

  50. 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

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