Chest pain in children: Difference between revisions
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==Historical Perspective== | ==Historical Perspective== | ||
Chest pain in children is a common symptom and | Chest pain in children is a common symptom and has a broad etiology. usually, history and physical examination can determine the cause and help in the differentiation of patients who require further investigations. | ||
==Classification== | ==Classification== | ||
Chest pain in children can be classified to: | Chest pain in children can be classified to: | ||
*Cardiac | *Cardiac | ||
*Non cardiac | *Non-cardiac | ||
==Pathophysiology== | ==Pathophysiology== | ||
*The pathogenesis of chest pain differs according to the cause may be: | ** The pathogenesis of chest pain differs according to the cause may be: | ||
*Inflammatory process in myocarditis, pericarditis, Kawasaki disease, Asthma, | ** Inflammatory process in myocarditis, pericarditis, Kawasaki disease, Asthma, pneumonia, esophagitis, and costochondritis. | ||
*Hypertrophy in hypertrophic cardiomyopathy. | ** Hypertrophy in hypertrophic cardiomyopathy. | ||
* | * | ||
==Causes== | ==Causes== | ||
Common causes of Chest pain in | Common causes of Chest pain in children include: | ||
'''Non Cardiac Causes:''' | '''Non Cardiac Causes:''' | ||
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Miscellaneous | Miscellaneous | ||
#Psychogenic and | #Psychogenic and Anxiety | ||
#Sickle cell disease | #Sickle cell disease | ||
#Herpes zoster | #Herpes zoster | ||
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*Mitral valve prolapse | *Mitral valve prolapse | ||
*Aortic stenosis | *Aortic stenosis | ||
*Aortic | *Aortic aneurysm | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
*Patients with chest pain account for 650,000 visits annually in patients age group from10 to 21 years. | *Patients with chest pain account for 650,000 visits annually in patients age group from10 to 21 years. | ||
*Patients with chest pain account for 5.2% of all cardiology consultations in inpatient and emergency | *Patients with chest pain account for 5.2% of all cardiology consultations in the inpatient and emergency departments. and 15% of all outpatient visits. | ||
*Studies estimated only 0% to 5% of patients with chest pain have a cardiac etiology. | *Studies estimated only 0% to 5% of patients with chest pain have a cardiac etiology. | ||
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*The majority of patients with chest pain have bengin non cardiac causes. | *The majority of patients with chest pain have bengin non cardiac causes. | ||
*Prognosis is generally good in non cardiac causes. | *Prognosis is generally good in non-cardiac causes. | ||
==Diagnosis== | ==Diagnosis== | ||
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:*Chest wall pain | :*Chest wall pain | ||
:*Dyspnea | :*Dyspnea | ||
:*Cough | :*Cough | ||
:* | :*Heartburn | ||
:*Pain after taking medications | :*Pain after taking medications | ||
:*Fever | :*Fever | ||
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===Physical Examination=== | ===Physical Examination=== | ||
*Physical examination may | *Physical examination may reveal: | ||
:*Chest wall tenderness in muscle strain and costochondritis | :*Chest wall tenderness in muscle strain and costochondritis | ||
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:*Peripheral edema | :*Peripheral edema | ||
:*Cyanosis | :*Cyanosis | ||
:*Tachypnea | :*Tachypnea | ||
:*Skin rash | :*Skin rash | ||
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===Electrocardiogram=== | ===Electrocardiogram=== | ||
An ECG should be obtained if cardiac disease is suspected and when a noncardiac etiology is not clear. | An ECG should be obtained if a cardiac disease is suspected and when a noncardiac etiology is not clear. | ||
ECG abnormalities can help with diagnosis: | ECG abnormalities can help with diagnosis: | ||
* | *Dysrhythmia. However, in intermittent events, the initial ECG will be normal. | ||
*Hypertrophic cardiomyopathy: left ventricular hypertrophy or strain. | *Hypertrophic cardiomyopathy: left ventricular hypertrophy or strain. | ||
*Pericarditis: generalized ST segment elevation followed by T wave inversion. | *Pericarditis: generalized ST-segment elevation followed by T wave inversion. | ||
*Myocarditis: ST-T wave abnormalities. | *Myocarditis: ST-T wave abnormalities. | ||
*Anomalous origin of the left coronary artery from the pulmonary artery: anterolateral infarction with deep and wide Q waves and T wave inversions in leads I, aVL, V5, and V6. | *Anomalous origin of the left coronary artery from the pulmonary artery: anterolateral infarction with deep and wide Q waves and T wave inversions in leads I, aVL, V5, and V6. | ||
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An x-ray may be helpful in the diagnosis of the cause of chest pain. | An x-ray may be helpful in the diagnosis of the cause of chest pain. | ||
x-ray may | The x-ray may show: | ||
*Cardiac enlargement in myocarditis and pericardial effusion | *Cardiac enlargement in myocarditis and pericardial effusion | ||
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===Echocardiography or Ultrasound=== | ===Echocardiography or Ultrasound=== | ||
-Echocardiography may | -Echocardiography may show many incidental findings but also it can help in the diagnose of serious causes of chest pain, including hypertrophic cardiomyopathy, anomalous coronary artery origin, pericardial effusion, and pulmonary hypertension. | ||
-Echocardiography is indicated in the patients with the following: | -Echocardiography is indicated in the patients with the following: | ||
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===CT scan=== | ===CT scan=== | ||
CT scan may be helpful in the diagnosis of the cause of chest pain, including pulmonary embolism, aortic aneurysm and | CT scan may be helpful in the diagnosis of the cause of chest pain, including pulmonary embolism, aortic aneurysm and dissection, and tumors. | ||
===MRI=== | ===MRI=== | ||
MRI scan may be helpful in the diagnosis of the cause of chest pain, including myocarditis, Arrhythmogenic right ventricular dysplasia (ARVD) and tumors. | MRI scan may be helpful in the diagnosis of the cause of chest pain, including myocarditis, Arrhythmogenic right ventricular dysplasia (ARVD), and tumors. | ||
===Other Diagnostic Studies=== | ===Other Diagnostic Studies=== | ||
Holter monitoring to | Holter monitoring to diagnose arrhythmia as a cause of intermittent chest pain. | ||
==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
The | The management depends on the clinical status and stability of the patient, patients with severe respiratory distress, hemodynamic instability require rapid care of the (ABC) airway, breathing, and circulation according to the Pediatric Advanced Life Support (PALS). | ||
The medical | The medical management of stable patients differs according to the cause: | ||
*Costochondritis and ms strain can be treated with NSAIDs and muscle relaxants. | *Costochondritis and ms strain can be treated with NSAIDs and muscle relaxants. | ||
*Infections like pneumonia can be treated with antibiotics, supplemental oxygen, and mechanical ventilation as needed | *Infections like pneumonia can be treated with antibiotics, supplemental oxygen, and mechanical ventilation as needed | ||
*Gastritis and esophagitis can be treated with H2 blockers and PPIs. | *Gastritis and esophagitis can be treated with H2 blockers and PPIs. | ||
*Acute chest syndrome in sickle cell disease managed with pain control, | *Acute chest syndrome in sickle cell disease managed with pain control, antibiotics, hydration and blood transfusion, or exchange transfusion. | ||
*Pulmonary embolism requires anticoagulant therapy or, thrombolytics in | *Pulmonary embolism requires anticoagulant therapy or, thrombolytics in hemodynamically unstable children. | ||
*Ischemia and myocardial infarction should receive anticoagulation, pain management, and catheterization. | *Ischemia and myocardial infarction should receive anticoagulation, pain management, and catheterization. | ||
*Heart failure should managed with diuretics, ACEIs, and beta blocker if no contrindication. | *Heart failure should be managed with diuretics, ACEIs, and beta-blocker if no contrindication. | ||
*Tachyarrhythmias should be managed according to Pediatric Advanced Life Support (PALS). | *Tachyarrhythmias should be managed according to Pediatric Advanced Life Support (PALS). | ||
* | *Pericarditis with pericardial effusion requires pericardiocentesis in patients with tamponade. | ||
*Tumors require further | *Tumors require further workup and the management differs according to the type of the tumor. | ||
===Surgery=== | ===Surgery=== | ||
*Aortic root dissection managed with | *Aortic root dissection managed with requires emergent surgical intervention. | ||
*Tension pneumothorax requires needle or chest tube thoracostomy. | *Tension pneumothorax requires a needle or chest tube thoracostomy. | ||
*Airway foreign body with obstruction requires emergent securing of the airway and bronchoscopy. | *Airway foreign body with obstruction requires emergent securing of the airway and bronchoscopy. | ||
*Esophageal foreign body: management depends on the type of body. sharp foreign bodies, impacted batteries, or magnets | *Esophageal foreign body: management depends on the type of body. sharp foreign bodies, impacted batteries, or magnets require urgent removal. | ||
==References== | ==References== | ||
Revision as of 20:15, 19 February 2021
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:
Synonyms and keywords: Chest pain in kids
Overview
Historical Perspective
Chest pain in children is a common symptom and has a broad etiology. usually, history and physical examination can determine the cause and help in the differentiation of patients who require further investigations.
Classification
Chest pain in children can be classified to:
- Cardiac
- Non-cardiac
Pathophysiology
- The pathogenesis of chest pain differs according to the cause may be:
- Inflammatory process in myocarditis, pericarditis, Kawasaki disease, Asthma, pneumonia, esophagitis, and costochondritis.
- Hypertrophy in hypertrophic cardiomyopathy.
Causes
Common causes of Chest pain in children include:
Non Cardiac Causes:
Idiopathic
Musculoskeletal
- Muscle strain
- Trauma
- Costochondritis
- Precordial catch syndrome
Respiratory
- Asthma
- Pneumonia
- Pneumothorax
- Pulmonary embolism
- Inhaled foreign body.
- Chronic cough
Gastrointestinal
- Gastroesophageal reflux( GERD)
- Esophagitis
- Gastritis
- Foreign body
Miscellaneous
- Psychogenic and Anxiety
- Sickle cell disease
- Herpes zoster
Cardiac Causes:
- Anomalous coronary arteries
- Kawasaki disease
- Dysrhythmias
- Pericarditis
- Myocarditis
- Hypertrophic cardiomyopathy
- Mitral valve prolapse
- Aortic stenosis
- Aortic aneurysm
Epidemiology and Demographics
- Patients with chest pain account for 650,000 visits annually in patients age group from10 to 21 years.
- Patients with chest pain account for 5.2% of all cardiology consultations in the inpatient and emergency departments. and 15% of all outpatient visits.
- Studies estimated only 0% to 5% of patients with chest pain have a cardiac etiology.
Natural History, Complications and Prognosis
- The majority of patients with chest pain have bengin non cardiac causes.
- Prognosis is generally good in non-cardiac causes.
Diagnosis
Symptoms
Symptoms of chest pain may include the following:
- Chest wall pain
- Dyspnea
- Cough
- Heartburn
- Pain after taking medications
- Fever
Physical Examination
- Physical examination may reveal:
- Chest wall tenderness in muscle strain and costochondritis
- Murmur, gallop, pericardial friction rub, distant heart sounds, and abnormal second heart sound (loud S2)
- Irregular rhythm,
- Peripheral edema
- Cyanosis
- Tachypnea
- Skin rash
Laboratory Findings
- Cardiac troponin
- CBC
- CRP
- ESR
Electrocardiogram
An ECG should be obtained if a cardiac disease is suspected and when a noncardiac etiology is not clear.
ECG abnormalities can help with diagnosis:
- Dysrhythmia. However, in intermittent events, the initial ECG will be normal.
- Hypertrophic cardiomyopathy: left ventricular hypertrophy or strain.
- Pericarditis: generalized ST-segment elevation followed by T wave inversion.
- Myocarditis: ST-T wave abnormalities.
- Anomalous origin of the left coronary artery from the pulmonary artery: anterolateral infarction with deep and wide Q waves and T wave inversions in leads I, aVL, V5, and V6.
- Pulmonary hypertension: signs of right ventricular hypertrophy and right axis deviation.
- Pulmonary embolism: nonspecific ST-T segment changes or sinus tachycardia.
X-ray
An x-ray may be helpful in the diagnosis of the cause of chest pain.
The x-ray may show:
- Cardiac enlargement in myocarditis and pericardial effusion
- Prominent main and central pulmonary arteries. in pulmonary hypertension
- infiltrates in pneumonia
- atelectasis
- Hyperinflation in asthma.
- Pneumothorax, pneumomediastinum, or pleural effusions.
- Radio-opaque esophageal foreign body (eg, button battery, or coin).
Echocardiography or Ultrasound
-Echocardiography may show many incidental findings but also it can help in the diagnose of serious causes of chest pain, including hypertrophic cardiomyopathy, anomalous coronary artery origin, pericardial effusion, and pulmonary hypertension.
-Echocardiography is indicated in the patients with the following:
- Exertional chest pain or syncope.
- Chest pain associated with fever.
- History of congenital heart disease, Kawasaki syndrome, or diseases that raise cardiac risk (eg, malignancy, hypercoagulable state).
- Family history of cardiomyopathy, sudden death.
- New murmur
- Distant heart sounds
- Pericardial friction rub
- Loud S2
- Peripheral edema
- Abnormal electrocardiogram.
CT scan
CT scan may be helpful in the diagnosis of the cause of chest pain, including pulmonary embolism, aortic aneurysm and dissection, and tumors.
MRI
MRI scan may be helpful in the diagnosis of the cause of chest pain, including myocarditis, Arrhythmogenic right ventricular dysplasia (ARVD), and tumors.
Other Diagnostic Studies
Holter monitoring to diagnose arrhythmia as a cause of intermittent chest pain.
Treatment
Medical Therapy
The management depends on the clinical status and stability of the patient, patients with severe respiratory distress, hemodynamic instability require rapid care of the (ABC) airway, breathing, and circulation according to the Pediatric Advanced Life Support (PALS).
The medical management of stable patients differs according to the cause:
- Costochondritis and ms strain can be treated with NSAIDs and muscle relaxants.
- Infections like pneumonia can be treated with antibiotics, supplemental oxygen, and mechanical ventilation as needed
- Gastritis and esophagitis can be treated with H2 blockers and PPIs.
- Acute chest syndrome in sickle cell disease managed with pain control, antibiotics, hydration and blood transfusion, or exchange transfusion.
- Pulmonary embolism requires anticoagulant therapy or, thrombolytics in hemodynamically unstable children.
- Ischemia and myocardial infarction should receive anticoagulation, pain management, and catheterization.
- Heart failure should be managed with diuretics, ACEIs, and beta-blocker if no contrindication.
- Tachyarrhythmias should be managed according to Pediatric Advanced Life Support (PALS).
- Pericarditis with pericardial effusion requires pericardiocentesis in patients with tamponade.
- Tumors require further workup and the management differs according to the type of the tumor.
Surgery
- Aortic root dissection managed with requires emergent surgical intervention.
- Tension pneumothorax requires a needle or chest tube thoracostomy.
- Airway foreign body with obstruction requires emergent securing of the airway and bronchoscopy.
- Esophageal foreign body: management depends on the type of body. sharp foreign bodies, impacted batteries, or magnets require urgent removal.