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
Dec 23, 2015
Jennifer Thull Thull-Freedman, MD, MSCI, FAAP(PEM)Assistant Professor of Paediatrics
University of TorontoCo Co-director, PEM Clinical Fellowship
The Hospital for Sick Children
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 achesArrived several hours later alert but in painHR=130, BP not doneCXR obtainedChild waited in room for CXR to be reviewed
From my residency Child suddenly became unresponsive and
pulselessUnable to be resuscitatedCXR reviewed during resuscitation showedwidened mediastinumAutopsy revealed dissection of the aorta
HoweverMost cases of chest pain in children are not
related to serious pathologyHistory and physical exam often sufficient
evaluation
The challengeObjectives
Review relevant literatureReview common causes of chest pain in
childrenDiscuss uncommon but serious causesPresent an approach to the child with chest
painSummarize take take-home points
Etiology of chest pain in kids
Very few studiesMost retrospectiveVariable inclusion/exclusion criteriaLimited detail provided
Selbst et alObjectives:Identify causes of chest pain in childrenAssess value of echocardiogramProspectiveEnrolled all patients with chest painECG and echo offered to those with ill ill-
defined or suspected cardiac etiologyPediatricsPediatrics1988; 82: 3191988; 319--
323323
Selbst et al.
Population407 patientsPhiladelphia, PennsylvaniaMedian age 12.5 years55% female, 90% African African-American43% acute pain <48 hoursDid not exclude known diseasePediatricsPediatrics1988; 82: 3191988; 319--
323323
Selbst et al.
ECG ECG’s in 191/235 children31 abnormal (16%)27 minor or previously known findings3 dysrhythmias detected on physical exam1 with known SLE had findings of pericarditisPediatricsPediatrics1988; 82: 3191988; 319--
323323
Selbst et al.
Echocardiograms in 139/23517 abnormal (12%)
12 mitral valve prolapse (8.6%)Similar prevalence to general population
2 pericardial effusion2 mitral valve regurgitation1 poor LV functionPediatricsPediatrics1988; 82: 3191988; 319--
323323
Selbst et al.
Chest radiographs in 137/40737 abnormal (27%)
Most frequent: infiltrates, atelectasis, hyperinflation
1 pneumothorax in a child with Marfan Marfan’s syndrome
1 clavicle fracture suspected clinically1 child with SLE had pleural effusion, large heart
PediatricsPediatrics1988; 82: 3191988; 319--323323
Selbst et al.
Organic disease related toAge <12 yearsPain awakening child from sleepAcute onsetAbnormal physical examNot related to description or location of painPediatricsPediatrics1988; 82: 3191988; 319--
323323
Selbst et al. #2
6-month follow follow-up of 149/407 patients43% had intermittent or persistent painNo significant disease identified
1 mitral valve prolapse1 gastrointestinal disease3 asthma
Conclusion:H&P sufficient for identifying majority of
significant etiologiesClinical PedsPeds1990; 29: 3741990; 374--77
Rowe et al.
Chest X X-rays done in 50%18/161 with positive result
15 infiltrates2 pneumomediastinum1 pneumothorax
ECG done in 18%2/60 with significant new findingsTachycardia and ST changes suggested
myocarditisWPW
CMAJCMAJ1990; 143:3881990; 388--9494
Massin et al.9 cases cardiac etiology in 168 PED patients
3 SVT2 MVP4 sick sinus1 myocarditis1 pericarditis1 cardiac hemochromatosis with β-thalassemia
5 cases cardiac etiology in 69 card. clinic patients
5 SVTClin Pediatr 2004;43:231 231
Massin et al.Results
Palpitations or abnormal auscultation predicted all
cases of cardiac diseaseConclusions
Chest pain in children usually benignHistory and physical usually sufficientLaboratory testing guided by H&P
Clin Pediatr 2004;43:231 231-
Limitations of current literature
Small numbers for characterizing rare eventsLimited detailChildren with known disease not excludedLack of follow follow-upNo evidence evidence-based guidelines
Differential Diagnosis
Chest wall Trauma Costochondritis Precordial catch Slipping rib Infection Mastalgia Zoster
Gastroesophageal Reflux Foreign body
Pulmonary Asthma Pneumonia/effusion Pneumothorax Pleurisy Pulmonary embolus Malignancy
Hematologic Sickle cell disease Psychogenic
Differential Diagnosis
CardiacAngina
Coronary abnormalitiesHypercoagulable stateCocaine
Obstructive heart diseaseIHSS, aortic stenosis
Pericardial effusion/pericarditisArrhythmiasMyocarditisAortic aneurysm
Cases
CaseA 12-year year-old girl presents to the
emergency department with chest pain for 2 days
Started graduallyWorse with deep breathHad URTI last weekAfebrileTender on both sides of sternumRemainder of physical exam normal
Costochondritis
Inflammation of costochondral cartilageCause
OverusePreceding URTI with coughIdiopathic
Sharp pain, worse with movementAll agesTenderness over costochondral joints
Case
A 10 10-year year-old boy presents to the ED with recurrent episodes of left chest pain.
Feels like a sudden stabCan’t take a deep breathLasts 2 2-3 minutesOccurs at restNot reproducibleNormal physical exam
Precordial Catch Syndrome
“Texidor’s twinge”Sudden, briefOccurs at restLocalizedSharpExacerbated by deep breathNo associated symptomsNo physical findings
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 paleNow looks and feels betterHR=110, normal physical exam
SVT
In children >1 year 82% present with palpitations 14% with pain
14% perspiration14% dizzy4% pallor
1-3% of chest pain complaints in ED6% of chest pain referred to cardiologistMedian time from symptoms to diagnosis 138d
CaseA 13 13-year year-old boy presents to the
emergency department with sudden severe chest painSharp pain in anterior chestAppears anxiousBP 80/40 in right armDiastolic murmur
Marfan syndromeCaused by fibrillin gene mutationManifestations
Musculoskeletal: Tall, long limbs and fingers, pectus
Ocular: Lens dislocationCardiovascular: Aortic root dilation, MVPPulmonary: Spontaneous pneumothorax
50% have aortic root dilation by age 10 years90% have aortic root dilation by age 20 years
Aortic dissection
Children at riskMarfan syndromeEhlers-DanlosCoarctationAortic stenosisTurner syndromeEndocarditisCocaine use
CaseA 17-year year-old female presents to the ED
with chest pain that has lasted for 1 hourPain began during soccer practiceHas happened previously with exerciseMidsternal, squeezing, radiates to left armPMH: Admitted to hospital for FUO at age 2
years
Kawasaki Disease
Acute febrile vasculitis of childhoodFeatures
Fever (>39 degrees for 5 days)Non Non-exudative conjunctivitisErythema of oral mucosa and tongueErythema and swelling of hands and feetCervical adenitis >1.5 cmRash
Leading cause of acquired heart disease in kids
Cardiac sequelae of KDAcute and subacute
Myocarditis (50% of patients)PericarditisMitral, aortic insufficiencyArrhythmias
Coronary aneurysms20 20-25% if untreated5% if treated with IVIGAppear 7 days to 4 weeks after onset of fever
Cardiac sequelae of KD
Long-term follow follow-up (> 10 years) of 594 untreated patientsIVIG treatment standard since late 1980 1980’s24.6% had coronary aneurysms
49% had regression 19% developed stenosis (4% of total) 8% developed myocardial infarction (2% of total)
Circulation1996;94:1379-85
Myocardial ischemia in kidsAnomalous coronary arteriesPrevalence 2:1000Anomalous origin of L coronary from pulm.
ArteryPresents in first months of lifeIrritability, heart failure, cardiac enlargement
Anomalous origin from incorrect sinus of ValsalvaPresents later in childhoodCompression between aorta and pulm Artery
Hypoplastic coronary arteries
Myocardial ischemia in kids
Sickle cell diseaseMyocardial infarction uncommon but describedPerfusion defects in 5% children studied in a
Paris sickle cell clinic ( Arch Dis Child 2004;89:359 359-62)
Microvascular occlusion of small vesselsExchange transfusion may be helpful for acute
ischemia ( Pediatrics 2003;111:e183 e183-7)
Myocardial ischemia in kids
Nephrotic syndromeThrombotic occlusion of coronary arteries
Long Long-standing diabetes mellitusFamilial hypercholesterolemiaSLE, Antiphospholipid antibody syndromesCardiac transplantCocaine abuse
CaseA 16-year year-old boy presents to the
emergency department after fainting at a track meet
Remembers having chest pain during his raceFather died suddenly in his 30 30’sSystolic murmur on exam
Hypertrophic cardiomyopathy
Autosomal dominantSymptoms in 2 2nd nd decadeMay present with angina angina-like pain or
syncopeImpaired diastolic relaxation, increased O O2
demandRisk of sudden death 6% in children
Hypertrophic cardiomyopathyCaseA 6-year year-old girl presents to the ED
with cough for 3 weeks and chest pain for 1 week
Feels very tiredIllness began with URTI 3 weeks agoAfebrileHeart rate = 160Liver palpable 3 cm below RCM
Myocarditis
Usually viral etiologyEnterovirus (coxsackie), adenovirus
PresentationHeart failureChest pain
More likely in older kids and adultsIschemia or concurrent pericarditis
Myocarditis
Physical findingsTachycardia, tachypneaPoor perfusionMuffled heart sounds, S3, murmurHepatomegaly
CXRCardiomegalyPulmonary edema
MyocarditisECG
Sinus tachycardiaDecreased voltages (<5 mm) limb leadsLVHProlonged PR interval, prolonged QT interval
EchocardiogramHypokinesis, impaired function
Hypertrophic cardiomyopathy
CaseA 6-year year-old girl presents to the ED with
coughfor 3 weeks and chest pain for 1 weekFeels very tiredIllness began with URTI 3 weeks agoAfebrileHeart rate = 160Liver palpable 3 cm below RCM
Pericarditis
Infectious etiology common in childrenPain
More common in older children and adolescents
Worse when supine, relieved by leaning forward
Physical findingsFriction rub if effusion smallMuffled heart sounds, pulsus paradoxus if
large
Pericarditis
ECGLow voltagesST elevation
Usually leads I, II, V5, V6
Electric alternansProduced by swinging motion of heart within
effusion
CaseA 9-year year-old obese boy is brought to the
ED at11 pm complaining of chest pain since dinner
preventing him from sleepingHas been having episodes for few weeksDescribed as burningWorse after big meals and when lying downNormal physical exam
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 groupResults: 78% had gastroesophageal cause
16 of 27 (59%) had esophagitis4 of 27 (15%) had gastritis1 of 27 (4%) with abnormal manometry
Gastroesophageal RefluxAccounts for 5 5-10% of PED chest pain visitsClassic pain is temporally associated with
mealsBurning, retrosternalTrial of antacid, H2RA, PPI is appropriateConsider pH probe if diagnostic testing
needed
Case
A 3 3-year year-old boy is evaluated in the emergency department with chest pain for several hoursPoints to sternal notchDroolingRefusing juiceAfebrile, well well-appearingBreath sounds equal
Esophageal foreign bodyCaseAn 8 8-year year-old boy is brought to the ED
directlyfrom a hockey practice during which he said
his chest hurt and he couldn couldn’t breathe Several similar episodesFeeling better since arrival to EDTight coughNormal breath sounds, no murmurNormal CXR and EKG
AsthmaMay account for 10 10-20% chest pain in kidsPersonal or family history atopic conditionsAssociated with coughMay be worse at night or with exerciseWheezing not always detectableTrial of bronchodilatorConsider PFT for pain with exercise
Case
A 17 17-year year-old boy presents to the emergency department with right chest painJust returned hours ago from vacation in
CozumelPain began one day agoProgressive dyspnea during flight home
Pneumothorax/pneumomediastinum
Children at riskAsthma, bronchiolitisBarotraumaCough, choking, vomitingCrack, cannabisCystic fibrosisMarfan syndromeTall male teenagers
Case
A 15-year year-old girl presents to the ED with chest
pain Present for several daysReports feeling dizzy and short of breathNot associated with exercisePhysical exam unremarkableGrandmother died last week of heart attack
PsychogenicPsychogenic5-20% of chest pain in childrenMore common in adolescentsRecent or current stressful situationFamily illness, especially cardiovascularFamily history of chest painOther somatic and sleep complaintsDepression
The approach: History
Description of painNot as reliable in children as in adultsPrecipitating factors
ExertionEatingDeep breathingMuscle useTraumaEmotional stress
The approach: History
Frequency and chronicityAssociated symptoms
FeverCoughShortness of breathSyncopeDizzinessPalpitations
The approach: History
The approach: HistoryPast medical historyKnown heart diseaseAsthma or atopic conditionsProthrombotic conditions
Cancer SLE Nephrotic syndrome
Medications and drugsFamily history
The approach: Physical examGeneral appearanceBody habitusVital signsChest wall palpationAuscultationAbdomenPeripheral perfusion
Red flags
Pain associated with exercise, palpitations, or syncope
Shortness of breath Pain limits daily activities or disturbs sleep Substance abuse Presence of prothrombotic conditions PMH consistent with Kawasaki disease Family history of sudden death or early cardiac
death Abnormal vital signs or physical findings
The approach
Further evaluationCXRECGHolter monitorEchocardiogramCardiology consultationTherapeutic trials
SummaryChest pain in pediatrics usually due to
benign,identifiable etiologyCardiac and other life life-threatening causes
ofchest pain rare but do existOften can be ruled out by history and
physical examDiagnostic tests appropriate in presence of
red flags