Chest pain resident survival guide (pediatrics): Difference between revisions
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{{familytree | | | | | | | | | | | | | | A01 | | |A01=''[[Psychogenic origin]]'', [[School problem]], [[family]] troubles such as [[parents divorce]]}} | {{familytree | | | | | | | | | | | | | | A01 | | |A01=''[[Psychogenic origin]]'', [[School problem]], [[family]] troubles such as [[parents divorce]]}} | ||
{{familytree | | | | | | | | | | B01 |-|.|!|,|-| B02 | | | | | | | |B01=''[[Gastrointestinal]] origin'', [[chest pain]] associated with [[indigestion]], [[heart burn]], [[vomiting]],|B02=''[[Cardiac]] origin'', [[Congenital heart disease]], [[kawasaki]], [[arrhythmia]]}} | {{familytree | | | | | | | | | | B01 |-|.|!|,|-| B02 | | | | | | | |B01=''[[Gastrointestinal]] origin'', [[chest pain]] associated with [[indigestion]], [[heart burn]], [[vomiting]],|B02=''[[Cardiac]] origin'', [[Congenital heart disease]], [[kawasaki]], [[arrhythmia]]}} | ||
{{familytree | | | | | | C01 |-|-|-|-|-| C02 |-|-|-|-|-| C03 | | | |C01=''[[Ideopathic]]'', No evidence of any organic etiology or any [[psychologic]] factors|C02=Characteristics of [[chest pain]]|C03=Squeezing, sharp, dull, duration of [[chest pain]]}} | {{familytree | | | | | | C01 |-|-|-|-|-| C02 |-|-|-|-|-| C03 | | | |C01=''[[Ideopathic]]'', No evidence of any organic etiology or any [[psychologic]] factors|C02='''Characteristics of [[chest pain]]'''|C03=Squeezing, sharp, dull, duration of [[chest pain]]}} | ||
{{familytree | | | | | | | | | | D01 |-|'|!|`|-| D02 | | | | | | | |D01= ''[[Musculoskeletal]] origin'', [[chest wall tenderness]],[[Pain]] aggravated with [[inspiration]],[[Muscle pain]] with movement,[[Tenderness]] on [[palpation]] of [[costochondral junction]]|D02=''[[Respiratory]] related'',[[Chest pain]] secondary to acute onset of [[cough]],[[wheezing]], [[asthma]]}} | {{familytree | | | | | | | | | | D01 |-|'|!|`|-| D02 | | | | | | | |D01= ''[[Musculoskeletal]] origin'', [[chest wall tenderness]],[[Pain]] aggravated with [[inspiration]],[[Muscle pain]] with movement,[[Tenderness]] on [[palpation]] of [[costochondral junction]]|D02=''[[Respiratory]] related'',[[Chest pain]] secondary to acute onset of [[cough]],[[wheezing]], [[asthma]]}} | ||
{{familytree | | | | | | | | | | | | | | B01 | | | | | | | | | |B01=<div style="float: left; text-align: left; height: 20em; width: 17em; padding:1em;"> '''Symptoms associated with [[Chest pain]] in [[children]] and [[adolescence]]:'''<br>❑ [[Cough]] (23.4%) <br> ❑ [[Dyspnea]] (11%) <br> ❑ [[Abdominal pain]] (9.7%) <br> ❑ [[Palpitation]] (9.7%) <br> ❑ [[Respiratory related]] (9%) <br> ❑ [[Dizziness]] (5.8%)<br>❑ [[Post nasal drip]] (4.4%) <br>❑ [[Fever]] (5.2%) <br> ❑ [[Exercise induced]] (2.6%) <br>❑ [[Syncope]] (2.6%) <br></div>}} | {{familytree | | | | | | | | | | | | | | B01 | | | | | | | | | |B01=<div style="float: left; text-align: left; height: 20em; width: 17em; padding:1em;"> '''Symptoms associated with [[Chest pain]] in [[children]] and [[adolescence]]:'''<br>❑ [[Cough]] (23.4%) <br> ❑ [[Dyspnea]] (11%) <br> ❑ [[Abdominal pain]] (9.7%) <br> ❑ [[Palpitation]] (9.7%) <br> ❑ [[Respiratory related]] (9%) <br> ❑ [[Dizziness]] (5.8%)<br>❑ [[Post nasal drip]] (4.4%) <br>❑ [[Fever]] (5.2%) <br> ❑ [[Exercise induced]] (2.6%) <br>❑ [[Syncope]] (2.6%) <br></div>}} |
Revision as of 05:15, 21 February 2021
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:
Synonyms and keywords:
Chest pain resident survival guide (pediatrics) Microchapters |
---|
Overview |
Causes |
FIRE |
Diagnosis |
Treatment |
Do's |
Don'ts |
Overview
Chest pain is the second cardiac symptom after cardiac murmur that is referred to a pediatric cardiologist for evaluation. the most common cause of chest pain in children is idiopathic without finding any specifice underlying problem and the second cause is musculoskeletal. Although there are high worries among parents about the cardiac origin of chest pain in children, it consists in low percentage the causes of chest pain. Evaluation of chest pain includes assessments of the respiratory system, gastrointestinal system, cardiac diseases and psychologic factors.
Causes
Life Threatening Causes
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
- Cardiac causes such as life-threatening arrhythmia, acute coronary syndrome, acute pulmonary embolism, tamponade
- Abdominal aorta dissection with propagation to thoracic aorta
- Perforated peptic ulcer
- Air leak syndrome such as Pneumothorax, pneumomediastinum
Common Causes
Causes of sharp chest pain |
Aspect |
Ideopathic (73.6%) |
|
Respiratory (9.3%) | |
Musculoskeletal (8.8%) | |
Cardiac (3.8%) | |
Gastrointestinal (2.9%) | |
Psychiatric (1.4%) |
FIRE: Focused Initial Rapid Evaluation
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
❑ Gastric lavage
❑PH probe
❑Upper GI series
❑Upper endoscopy
❑Abdominal sonography
❑Liver function test
❑Lipase, amylase
❑Serum gastrin level
❑Stool guaic testing
❑Skeletal radiography
❑Spine CT scan
❑ SpineMRI
❑Nuclear bone scan
❑Creatine kinase with MM fraction
❑ Viral, bacterial antibody level
❑Psychologic testing
❑Culture of blood, pericardial fluid, sputum
❑Urine, serum toxicology
❑Serum compelement level
❑Glycosylated Hb A1C
❑Hemoglobin electrophoresis
❑Cell blood count
❑Coagulation study
❑ESR
❑Mamography
❑ Breast sonography
❑Breast biopsy
❑Thyroid function test
Cardiac | Underlying congenital or acquired heart disease, arrhythmia, crushing chest pain, exercised induced chest pain, persistent tachycardia, hypotension, gallop rhythm, syncope, pericardial rub | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Pulmonary | Hemoptysia, tachypnea, rales,cyanosis, wheeze, pleural rub | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Physical examination | Gastrointestinal | Hematemesis,hematochezia, melena, epigastric tenderness, organomegaly, trauma | |||||||||||||||||||||||||||||||||||||||||||||||||||||
musculoskeletal | Chest Trauma, chest bruising, chest asymmetry, chest localised swelling, chest localized tenderness, crepitus on palpation, arm limited range of motion | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Other | Febrile, psychosis, suisidal ideation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Complete Diagnostic Approach
Shown below is an algorithm summarizing the diagnosis of pediatric chest pain according the the [...] guidelines.
Evaluation of chest pain | |||||||||||||||||||||||||||||||||||||||||||||
Medical history, cardiac examination | |||||||||||||||||||||||||||||||||||||||||||||
Abnormal history or cardiac examination | Normal history and cardiac examination | ||||||||||||||||||||||||||||||||||||||||||||
Yes | NO | ||||||||||||||||||||||||||||||||||||||||||||
Febrile, acute onset symptoms | Palpitation, chest pain, positive family history | ||||||||||||||||||||||||||||||||||||||||||||
Yes | NO | NO | Yes | ||||||||||||||||||||||||||||||||||||||||||
Refer to pediatric cardiologist | At rest chest pain, exersional chest pain | Refer to pediatric cardiologist | |||||||||||||||||||||||||||||||||||||||||||
Exertional chest pain | At rest chest pain or reproducible on exam | ||||||||||||||||||||||||||||||||||||||||||||
Suspected asthma | Low likehood of cardiac chest pain | ||||||||||||||||||||||||||||||||||||||||||||
Yes | NO | Reassurance | |||||||||||||||||||||||||||||||||||||||||||
Bronchodilator | Refer to pediatric cardiologist | ||||||||||||||||||||||||||||||||||||||||||||
Improvement | |||||||||||||||||||||||||||||||||||||||||||||
Keeping management | Refer to pediatric cardiologist | ||||||||||||||||||||||||||||||||||||||||||||
Charactristics of chest pain | |
---|---|
Musculoscletal origin |
|
| |
| |
Respiratory origin |
|
Gastrointestinal origin |
|
| |
Cardiac origin | |
Psychogenic origin | |
| |
Ideopathic |
|
❑ Gastric lavage
❑PH probe
❑Upper GI series
❑Upper endoscopy
❑Abdominal sonography
❑Liver function test
❑Lipase, amylase
❑Serum gastrin level
❑Stool guaic testing
❑Skeletal radiography
❑Spine CT scan
❑ SpineMRI
❑Nuclear bone scan
❑Creatine kinase with MM fraction
❑ Viral, bacterial antibody level
❑Psychologic testing
❑Culture of blood, pericardial fluid, sputum
❑Urine, serum toxicology
❑Serum compelement level
❑Glycosylated Hb A1C
❑Hemoglobin electrophoresis
❑Cell blood count
❑Coagulation study
❑ESR
❑Mamography
❑ Breast sonography
❑Breast biopsy
Thyroid function test
Symptoms associated with Chest pain in children and adolescence: ❑ Cough (23.4%) ❑ Dyspnea (11%) ❑ Abdominal pain (9.7%) ❑ Palpitation (9.7%) ❑ Respiratory related (9%) ❑ Dizziness (5.8%) ❑ Post nasal drip (4.4%) ❑ Fever (5.2%) ❑ Exercise induced (2.6%) ❑ Syncope (2.6%) | |||||||||||||||||||||
|}}
❑ Cough (23.4%)
❑ Dyspnea (11%)
❑ Abdominal pain (9.7%)
❑ Palpitation (9.7%)
❑ Respiratory related (9%)
❑ Dizziness (5.8%)
❑ Post nasal drip (4.4%)
❑ Fever (5.2%)
❑ Exercise induced (2.6%)
❑ Syncope (2.6%)
}}
Is there any red flag about cardiac etiology?: ❑ History of acquired or congenital cardiac disease ❑ Exertional syncope ❑ Exertional chest pain ❑ Hypercoagulable state ❑ Hypercholesterolemic state ❑ Family history of sudden death under 35 years of age ❑Family history of premature coronary artery disease ❑Inheritted arrhythmia in the first relative ❑ICD implantation ❑ Connective tissue disease ❑ Using cocaine, amphetamine | |||||||||||||||||||||||
Laboratory investigation in suspicion of cardiac etiology: ❑ EKG ❑ Exercise stress test ❑ Dobutamin stress test ❑ Thalium scan ❑ Serum creatine kinase with MB fraction ❑ Serum troponineI ❑Lipid profile ❑Pericardiocenthesis ❑Endomyocardial biopsy ❑ Catheterization | |||||||||||||||||||||||
Symptoms associated with Chest pain in children and adolescence: ❑ Cough (23.4%) ❑ Dyspnea (11%) ❑ Abdominal pain (9.7%) ❑ Palpitation (9.7%) ❑ Respiratory related (9%) ❑ Dizziness (5.8%) ❑ Post nasal drip (4.4%) ❑ Fever (5.2%) ❑ Exercise induced (2.6%) ❑ Syncope (2.6%) | |||||||||||||||||||||
Cardiac | Underlying congenital or acquired heart disease, arrhythmia, crushing chest pain, exercised induced chest pain, persistent tachycardia, hypotension, gallop rhythm, syncope, pericardial rub | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Pulmonary | Hemoptysia, tachypnea, rales,cyanosis, wheeze, pleural rub | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Physical examination | Gastrointestinal | Hematemesis,hematochezia, melena, epigastric tenderness, organomegaly, trauma | |||||||||||||||||||||||||||||||||||||||||||||||||||||
musculoskeletal | Chest Trauma, chest bruising, chest asymmetry, chest localised swelling, chest localized tenderness, crepitus on palpation, arm limited range of motion | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Other | Febrile, psychosis, suisidal ideation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Evaluation of chest pain | |||||||||||||||||||||||||||||||||||||||||||||
Medical history, cardiac examination | |||||||||||||||||||||||||||||||||||||||||||||
Abnormal history or cardiac examination | Normal history and cardiac examination | ||||||||||||||||||||||||||||||||||||||||||||
Yes | NO | ||||||||||||||||||||||||||||||||||||||||||||
Febrile, acute onset symptoms | Palpitation, chest pain, positive family history | ||||||||||||||||||||||||||||||||||||||||||||
Yes | NO | NO | Yes | ||||||||||||||||||||||||||||||||||||||||||
Refer to pediatric cardiologist | At rest chest pain, exersional chest pain | Refer to pediatric cardiologist | |||||||||||||||||||||||||||||||||||||||||||
Exertional chest pain | At rest chest pain or reproducible on exam | ||||||||||||||||||||||||||||||||||||||||||||
Suspected asthma | Low likehood of cardiac chest pain | ||||||||||||||||||||||||||||||||||||||||||||
Yes | NO | Reassurance | |||||||||||||||||||||||||||||||||||||||||||
Bronchodilator | Refer to pediatric cardiologist | ||||||||||||||||||||||||||||||||||||||||||||
Improvement | |||||||||||||||||||||||||||||||||||||||||||||
Keeping management | Refer to pediatric cardiologist | ||||||||||||||||||||||||||||||||||||||||||||
Causes of sharp chest pain |
Aspect |
Ideopathic (73.6%) |
|
Respiratory (9.3%) | |
Musculoskeletal (8.8%) | |
Cardiac (3.8%) | |
Gastrointestinal (2.9%) | |
Psychiatric (1.4%) |
Cardiac origin |
---|
History of acquired or congenital cardiac disease |
Exertional syncope |
Exertional chest pain |
Hypercoagulable state |
Hypercholesterolemic state |
Family history of sudden death under 35 years of age |
Family history of premature coronary artery disease |
Inheritted arrhythmia in the first relative |
ICD implantation |
Connective tissue disease |
Using cocaine,amphetamine |
Is there any red flag about cardiac etiology?: ❑ History of acquired or congenital cardiac disease ❑ Exertional syncope ❑ Exertional chest pain ❑ Hypercoagulable state ❑ Hypercholesterolemic state ❑ Family history of sudden death under 35 years of age ❑Family history of premature coronary artery disease ❑Inheritted arrhythmia in the first relative ❑ICD implantation ❑ Connective tissue disease ❑ Using cocaine, amphetamine | |||||||||||||||||||||||
Laboratory investigation in suspicion of cardiac etiology: ❑ EKG ❑ Exercise stress test ❑ Dobutamin stress test ❑ Thalium scan ❑ Serum creatine kinase with MB fraction ❑ Serum troponineI ❑Lipid profile ❑Pericardiocenthesis ❑Endomyocardial biopsy ❑ Catheterization | |||||||||||||||||||||||
Treatment
Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.
Cardiac causes such as IHD, pericarditis, tamponade, arrhythmia | Treatment of underlying causes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Musculoskeletal | Reassurance, rest,analgesic, antiinflammatory agent (NSAID), warm compression | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Treatment of pediatric chest pain | Pulmonary disease ( bronchitis, asthma, pleurisy, pleural effusion, pneumonia, empyema, bronchiectasis, lung abscess, | antibiotic therapy, bronchodilator therapy | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Gastrointestinal such as GERD, gastritis, cholecystitis | Antacid, H.pilory eradication , antibiotic therapy | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Psychologic | Cognitive behavior therapy | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do's
- Quickly evaluate cardiac examination in children presented with chest pain and syncope.
- Arrhythmia leading chest pain in children include: paroxysmal supraventricular tachycardia (PSVT), premature ventricular contraction (PVC), atrial flutter, mobitz type2 block ,atrial tachycardia, atrial premature contraction.
- Asthma is the most common cause of chest pain in the pulmonary group presenting with exertional chest pain.
- Think about pneumothorax among young adult male presented with tachypnea, persistent pleuritic chest pain for 1-2 days and take a chest-X-ray for evaluation of air leak syndrome.
- If the CXR is undiagnostic for evaluation of pneumomediastinum, chest CT-scan is considered.
- In patients with chest pain and hypoxia, pulmonary embolism should be noticed.
- Acute chest syndrome or pulmonary infarction can be the manifestation of sickle cell disease among children.
- In patients presented with GERD or gastritis, chest pain is described as burning pain in epigastric area related to taking food.
- Hyperventilation in patients with panic disorder or anxiety disorder may lead to chest pain, paresthesia, dizziness, shortness of breath.
- Chest pain may be initial presentation of deformities in chest wall such as scoliosis due to nerve root compression.
- Mitral valve prolapse may be present with atypical chest pain in children
- In case of marfan disease with sudden onset severe chest pain radiating to the back, dissection aorta aneurysm should be evaluated.
- In patients with history of arterial switch in transposition of the great arteries (d-TGA), ostial coronary artery stenosis should be noticed.
- Homozygous familial hypercholesterolemia may lead to coronary artery disease and ischemic chest pain in the first two decades in children.
Don'ts
- Do not hesitate for urgent evaluation of patients presented with chest pain accompanied with dyspnea or unstable hemodynamic.