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 PCH Emergency Department disclaimer.

Aim

To guide staff with the assessment and management of chest pain.

Background

  • There are many causes of chest pain in children, but less than 5% are due to cardiac or other life threatening disease.
  • In adolescents, most presentations with chest pain are psychosomatic or no cause is found.
  • Management is related to the underlying cause. 

Assessment

Could there be a cardiac cause?

Symptoms and signs for potential cardiac disease

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

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 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 CXR 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 CXR.

Could this be a Pulmonary Embolus?

Risk Factors for Pulmonary Embolus

  • Immobility or recent surgery
  • Neoplasm
  • Hypercoagulability
  • Central venous catheter
  • Pleuritic pain
  • Haemoptysis
  • Hypoxia
  • 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.

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
  • Intercostal muscle strain

Precordial catch

  • Classically, several seconds of severe chest and back pain occur, often when moving from slouching posture.
  • Treatment of musculoskeletal causes involves reassurance, rest and simple analgesia or non-steroidal anti-inflammatory medications.
  • Athletes with recurrent overuse injuries may benefit from a sports medicine referral.

Gastrointestinal Causes

Gastroesophageal reflux

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

Ingested foreign body 

Miscellaneous Causes

Breast tenderness

  • Related to hormonal changes at puberty or with pregnancy.

Shingles (pre-rash)

Trauma

Is there a serious underlying psychiatric cause?

  • In some studies, up to 10% of adolescents with chest pain may have a serious underlying psychiatric cause.
  • Most presentations with chest pain are psychosomatic or no cause found.

Risk factors for serious psychiatric disease

  • 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.

Panic Attacks

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 psychosomatic 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.

Bibliography

  1. Chest Pain in Children and Adolescents Surendranath R. Veeram Reddy, MD,* Harinder R. Singh, MD* Pediatrics in Review Vol.31 No.1 January 2010
  2. Textbook of Paediatric Emergency Medicine 2nd Edition Cameron Elesevier 2012
  3. Nelson Textbook of Pediatrics: 20th Edition Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Publisher: Elsevier 

Endorsed by:  Director, Emergency Department  Date:  Feb 2018


 Review date:   Jun 2020


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