Chest pain

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full CAHS Clinical disclaimer

Aim

To guide Emergency Department (ED) staff with the assessment and management of chest pain.

Background^1,2,3

• Chest pain is a common presentation in children.
• There are many causes of paediatric chest pain but often an underlying cause is not found
• Less than 1% are due to cardiac or other life threatening disease¹.
• Management is related to the underlying cause. 

Assessment^1,3

Could there be a cardiac cause?

Symptoms and signs for potential cardiac disease 

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

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 echocardiogram (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 chest X-ray 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 chest X-ray

Could this be a Pulmonary Embolus?

Risk factors for Pulmonary Embolus

• Immobility or recent surgery
• Neoplasm
• Hypercoagulability
• Central venous catheter

Symptoms and signs for Pulmonary Embolus

• The most frequent symptoms are pleuritic pain, dyspnoea, apprehension, cough and haemoptysis
• The most frequent signs are tachypnoea and tachycardia

Respiratory causes

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, and 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
• Treatment of musculoskeletal causes involves reassurance, rest and simple analgesia or non-steroidal anti-inflammatory medications

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
• Pain is reproducible on palpation
• Intercostal muscle strain

Precordial catch

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

Gastrointestinal Causes

Gastroesophageal reflux

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

Ingested foreign body 

• Sudden onset of pain while eating or after choking
• May have drooling and difficulty swallowing

Miscellaneous Causes

Breast tenderness

• Related to hormonal changes at puberty or with pregnancy.

Trauma

Shingles (pre-rash)

Psychogenic causes¹

• In some studies, up to 10% of adolescents with chest pain may have an underlying psychiatric cause.

Risk factors for serious psychiatric disease

• Recent stressful event
• 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

Anxiety Disorder

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 psychogenic 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

1. Barbut G & Needleman JP. Pediatric Chest Pain, Pediatr Rev (2020) 41 (9): 469–480
2. Reddy SRV & Singh HR. Chest Pain in Children and Adolescents, Pediatrics in Review Vol.31 No.1 January 2010
3. Geggel RL & Endom EE, Nontraumatic chest pain in children and adolescents: Approach and initial management. 2022. UpToDate
4. Textbook of Paediatric Emergency Medicine 3rd Edition Cameron P, Browne GJ, Mitra B, et al (2018) Publisher: Elsevier Edition updated
5. Nelson Textbook of Pediatrics: 21st Edition Robert M. Kliegman, St Geme JW, Blum MJ et al. 2020 Publisher: Elsevier

Endorsed by:	Nurse, Co-director, Surgical Services	Date:	Apr 2023
		Review date:	Mar 2026

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