SYMPOSIUM ON PGIMER PROTOCOLS ON RESPIRATORY EMERGENCIES

Acute Chest Pain

Atul Jindal & Sunit Singhi

Received: 27 January 2011 /Accepted: 8 March 2011 /Published online: 4 May 2011# Dr. K C Chaudhuri Foundation 2011

Abstract Chest pain is a worrisome symptom that oftencauses parents to bring their child to emergency department(ED) for evaluation. In the majority of cases, the etiology ofthe chest pain is benign, but in one-fourth of the casessymptoms are distressing enough to cause children to missschool. The clinician’s primary goal in ED evaluation ofchest pain is to identify serious causes and rule out organicpathology. The diagnostic evaluation includes a thoroughhistory and physical examination. Younger children aremore likely to have a cardiorespiratory source for theirchest pain, whereas an adolescent is more likely to have apsychogenic cause. Children having an organic cause ofchest pain are more likely to have acute pain, sleepdisturbance due to pain and associated fever or abnormalexamination findings, whereas those with non-organic chestpain are more likely to have pain for a longer duration. Chestradiograph is required in some, especially in patients withhistory of trauma . In children, myocardial ischemia is rare,thus routine ECG is not required on every patient. However,both pericarditis and myocarditis can present with chest painand fever. Musculoskeletal chest pain, such as caused bycostochondritis and trauma, is generally reproducible onpalpation and is exaggerated by physical activity or breathing.Pneumonia with or without pleural effusion, usually presentswith fever and tachypnea; chest pain may be presentingsymptom sometimes. In asthmatic children bronchospasm andpersistent coughing can lead to excess use of chest wallmuscles and chest pain. Patients’ who report acute pain andsubsequent respiratory distress should raise suspicion of aspontaneous pneumothorax or pneumomediastinum. ED

management includes analgesics, specific treatment directedat underlying etiology and appropriate referral.

Keywords Chest pain . Children . Osteochondritis .

Psychogenic chest pain

Introduction

Chest pain is a worrisome symptom that often causesparents to bring their child to emergency department(ED)for evaluation. No specific data from India on incidenceand causes of chest pain in children is available. In NorthAmerica, the incidence of pediatric patients presenting toED with a complaint of chest pain is 3–6 for every 1,000patient visits [1, 2]. In the majority of cases, the etiology ofthe chest pain is benign, but symptoms are distressingenough to cause 27–30% of children to miss school [2, 3].

Causes

The clinician’s primary goal in evaluating the chest pain isto identify serious causes and rule out organic pathology.There are numerous causes for pediatric chest pain; theseare listed in Table 1.

In general, the most frequently reported cause ismusculoskeletal pain, followed by respiratory causes.Despite extensive investigations, one may not find anycause in as many as 20–61% of cases [3–7] (Table 2).

Clinical Presentation

The clinical presentation of the pediatric patient with chest painvaries greatly. The average age at presentation is 10–12 years,

A. Jindal : S. Singhi (*)Department of Pediatrics, Advanced Pediatrics Centre,Postgraduate Institute of Medical Education and Research,Chandigarh 160012, Indiae-mail: sunit.singhi@gmail.com

Indian J Pediatr (October 2011) 78(10):1262–1267DOI 10.1007/s12098-011-0413-1

with an equal distribution between sexes [1–4]. Youngerchildren are more likely to have a cardiorespiratory source fortheir chest pain, whereas an adolescent is more likely to havepsychogenic cause [1, 3]. Children with non-organic chestpain are more likely to have pain for a longer duration andmore likely to have a family history of chest pain or heartdisease [3]. On the other hand, children having an organiccause of chest pain are more likely to have acute pain, sleepdisturbance due to pain and associated fever or abnormalexamination findings. Children often have difficulty inlocalising and qualifying their pain. In instances where thechild is able to localize chest pain (e.g. right sided, left sidedand sternal), no specific relationship to a particular diagnosisor diagnostic category has been found [1–3]. The descriptionof the pain (e.g. sharp, dull and aching) is also unrelated tothe actual diagnosis [3].

Evaluation

The diagnostic evaluation of pediatric patients presentingwith chest pain includes a thorough history and physicalexamination. Further diagnostic studies may be needed(Fig. 1). Chest radiograph is not required in every childwith chest pain, but should be ordered when there issuspicion of respiratory, cardiac or traumatic cause. Inchildren, myocardial ischemia is rare, thus routine ECG isalso not required on every patient. When a child presentswith chest pain, clinical features can provide a clue to thediagnosis.

Take a careful history and focus on:

History

& Acute onset of pain—likely to have an organic etiology& Pain wakes child from sleep—likely to have an organic

etiology& Pain associated with exertion, syncope—more likely to

be cardiac in nature, or exercise-induced asthma& Presence of Fever—Pneumonia; pleural effusion, Pleuritis

consider myocarditis, pericarditis& Midsternal burning pain (worsens when recumbent)—

gastroesophageal reflux& History of heart disease—pain is sometimes related to

underlying condition (often just anxiety about theunderlying condition)

Table 1 Differential diagnosis of pediatric chest pain

Idiopathic Abdominal and Gastrointestinal

Cardiovascular Esophagitis (gastroesophageal reflux disease, bulimia, pill esophagitis)Structural (hypertrophic cardiomyopathy, valvular stenosis[pulmonary, aortic], mitral valve prolapse)

Esophageal foreign body

Myocarditis

Esophageal spasm/dysmotility

PericarditisMusculoskeletal and Chest wall

Endocarditis

Chest wall strain (exercise, overuse injury, forceful coughing)

Coronary artery disease (anomalous coronary arteries,acute Kawasaki disease, premature atherosclerosis)

Skeletal (chest wall or thoracic spine) anomaly

Coronary artery vasospasm (toxicologic ingestion)

Trauma (contusion/rib fracture)

Arrhythmia

Costochondritis/Tietze syndrome

Aortic aneurysm or dissection(Marfan, Turner, and Noonan syndromes)

Slipping rib

Respiratory

Precordial catch (Texidor twinge)

Pneumonia

Breast tenderness

Pleuritis/pleural effusion

Cutaneous (e.g., herpes zoster)

Pleurodynia (coxsackie virus)

Psychiatric

Severe cough

Stress-related pain

Pneumothorax/pneumomediastinum

Hematologic and Oncologic

Asthma

Sickle cell disease

Pulmonary embolism

Chest wall, thoracic, or mediastinal tumor

Neurologic

Migraine

Spinal nerve root compression

Table 2 Frequency of causes of chest pain in children [3–9]

Cause Emergency department (%) Cardiology clinic (%)

Idiopathic 12–61 37–54

Musculoskeletal 7–69 1–89

Respiratory 13–24 1–12

Gastrointestinal 3–7 3–12

Psychogenic 5–9 4–19

Cardiac 2–5 3–7

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& Serious associated conditions (Kawasaki disease, asthma,Marfan syndrome, lupus)—these children are at risk forserious complications like ischemia, pneumothorax, pleuraleffusion

& Stressful life events that correlate with onset of pain—consider psychogenic pain (anxiety)

Physical examination: Check for:

& Respiratory distress, abnormal vital signs& Decreased breath sounds, palpable subcutaneous air—

consider pneumonia, pneumothorax, subcutaneousemphysema.

Child presenting with chest pain

Is there history of trauma?

Yes No

Chest X-Ray

Yes Fever and respiratory

findings

Chest X-Ray Consider Pulmonary Causes: Pneumonia

Asthma No No

Abnormal cardiac Exam If abnormal cardiac

exam, consider: EKG, ECHO for myocarditis and

pericarditis

If risk factors present, consider D-dimer & CT chest

for pulmonary embolism

Yes

EKG, Chest X-Ray Consider Structural

abnormality arrhythmia

Myocardial Ischemia

No If concerns for

myocardial ischemia, get troponins

Dysphagia, pain associated with

food, or epigastric pain

Yes Explore GI Causes, Consider Chest X-Ray

for Foreign body

No

Reproducible Pain? Overuse?

Yes Consider musculoskeletal causes

No

Recent Stressors? Yes Consider Psychogenic Cause

Idiopathic Needs close monitoring

Evaluation withchild psychologist

No

Fig. 1 Chest pain diagnostic algorithm

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& Wheezing—consider asthma and pain related to com-plications like pneumomediastinum, pneumothorax

& Abnormal cardiac findings (pathologic murmur, rub,arrhythmia)—consider pericarditis, myocarditis, supra-ventricular tachycardia, structural heart disease

& Evidence of trauma—consider pneumothorax, chestwall injury

& Reproducible pain—consider musculoskeletal pain,costochondritis

& Drooling in a young child—consider foreign bodyaspiration/inhalation (coin)

Always look for Red flag signs (Table 3).

In these patients chest pain could be a sign of seriousunderlying illness.

When to Consider Chest X-Ray and ECG?

Chest-radiograph is needed in all the patients with historyof trauma. In others it is indicated on basis of clinical signsgiven in Table 4.

Consider further testing:

& D-dimer, chest CT scan and if available radionuclidescan—if patient has increased risk for pulmonaryembolism (coagulation disorder, trauma)

& Holter monitor—if arrhythmia suspected& Exercise stress test, pulmonary function tests—if pain is

related to exercise& Child psychology evaluation.

Differential Diagnosis

Cardiac

Pediatric chest pain is rarely due to cardiac pathology.However, it is the second most common cause for referralto a pediatric cardiologist. Careful history and physical

examination are generally sufficient to diagnose cardiac-related chest pain. If not, they should at least be sufficientto guide the use of chest x-ray, ECG, and echocardiograms.

Pericarditis and myocarditis both can present with chestpain and fever. Pericarditis usually presents with sharp,substernal pain, which is alleviated by leaning forward. Onphysical examination, the patient classically has distantheart sounds, a friction rub, and signs of congestive heartfailure. Myocarditis patients often have vague symptomsincluding chest pain, dyspnoea, dizziness, nausea, vomitingand fatigue. Physical examination usually reveals a gallop,signs of congestive heart failure, and tachycardia unresponsiveto fluids.

Structural abnormalities of the heart and vessels cancause chest pain. Hypertrophic cardiomyopathy patientsusually give a history of increased chest pain with exertion.Aortic stenosis, pulmonary stenosis, abnormal coronaryarteries, and mitral valve prolapse, depending on theseverity, can lead to ischemia of the heart and papillarymuscles. History and physical examination of these patientstypically reveal a heart murmur associated with the lesion.

Arrhythmias can cause chest pain in the pediatric patient.Premature ventricular tachycardia can present as a fleeting,sharp pain, or palpitations. Supraventricular tachycardia(SVT) is usually described as a rapid heartbeat. Physicalexamination should cue the physician to the possibility ofSVT.

Myocardial infarction is rare in children, but has beenreported in literature in previously healthy adolescents[10, 11]. These patients usually present with classic severe,substernal chest pain with radiation to the left arm or jaw.Patients are at greater risk for myocardial ischemia if theyhave a history of congenital heart disease, acquired heartdisease (Kawasaki disease), or drug abuse (cocaine).

Respiratory

Pediatric chest pain attributed to a pulmonary etiology is usuallyaccompanied by other symptoms and signs of organic illness.Pneumonia with or without pleural effusion, usually presentswith fever, tachypnea, and respiratory symptoms. Physicalexamination may reveal decreased breath sounds or rales.

Patients presenting with a history of asthma or reactiveairway disease should prompt the physician to assess thepossibility of chest pain secondary to an asthma exacerbation.Bronchospasm and persistent coughing can lead to excess useof chest wall muscles and is a common cause of chest pain.

Patients’ who report acute pain and subsequent respiratorydistress should raise suspicion of a spontaneous pneumothoraxor pneumomediastinum. Patients with asthma, Marfansyndrome or cystic fibrosis are at increased risk of developingpneumothorax. Physical examination may reveal decreasedbreath sound on the affected side and crepitus depending on

Table 3 Chest pain in children—Red flag signs indicating seriousunderlying etiology

✓ Young age

✓ Acute onset

✓ Pain precipitated with exercise

✓ Pain associated with syncope

✓ Pain associated with palpitations

✓ Pain associated with respiratory distress

✓ Pain associated with abnormal cardiorespiratory examination

✓ Pain associated with trauma

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the extent of pathology. A hemothorax should be consideredif there is a history of trauma.

Pulmonary embolism is rare in children but should beconsidered in adolescents who complain of dyspnea,pleuritic chest pain, hemoptysis and low grade fever. Riskfactors for pulmonary embolism are prolonged immobility,hypercoagulable disorders, (including nephrotic syndrome)indwelling central lines and major trauma particularly to thelower extremities.

Chest wall deformities (pectus excavatum/pectus carina-tum) in children are sometimes associated with chest pain.They can lead to restricted lung function, and many arerelated to psychologic problems in children because of theassociated cosmetic defects.

Gastrointestinal

Gastrointestinal causes for pediatric chest pain make up 3–7%of ED visits. Gastroesophageal reflux disease often causes aburning substernal type of pain because of resulting gastritisand esophagitis. Epigastric tenderness on physical examina-tion and association of pain with eating is suggestive of agastrointestinal origin of the chest pain and should be furtherinvestigated. A trial of antacids is often diagnostic andtherapeutic.

Children that have ingested a foreign body that is lodged inesophagus can have chest pain. Patients may have dysphagiadepending on the location of foreign body. A careful historyand chest radiograph usually reveals the diagnosis.

Musculoskeletal

Musculoskeletal chest pain is generally considered when painis reproducible on palpation or suggested by a history ofmusclestrain or minor trauma. Reproducibility of chest wall pain isgenerally a goodmarker for costochondritis. However, absence

does not always exclude a musculoskeletal cause. Theduration of musculoskeletal chest pain can be relatively long.

Trauma can cause fractures and contusions that mayresult in chest pain. Overuse or overexertion of the chestwall muscles may cause muscle strain.

Costochondritis is a common condition which isrecognised by eliciting pain while palpating the costochondraljoints. The etiology of costochondritis is unknown but it isconsidered to be a benign inflammatory condition. It usuallyinvolves 4th to 6th costochondral junctions and produceslocalised tenderness. The pain is exaggerated by physicalactivity or breathing. A similar disease Tietze’s syndrome alsooccurs at costochondral junction but has the associated findingsof swelling, redness and warmth. Like costochondritis, Tietze’ssyndrome is thought to be a self limited inflammatory condition.

Slipping rib syndrome usually occurs at the false orfloating ribs. The patient describes a sharp intermittent painthat lasts a few minutes and settles to a dull ache. Theremay be a history of trauma and aggravation with movement.The pain is thought to result from the anterior end of ribsslipping out of place and aggravating the adjacent intercostalnerves. The hooking manoeuvre can be used to help diagnosethis condition. The patient is instructed to lie down on theunaffected side and the examiner reaches under the lowercoastal margin and pulls the rib anteriorly. A positive test resultsin the reproduction of the patient’s pain and click sensation.

Precordial catch syndrome or Texidor’s twinge syndromeis a benign condition that causes a brief sharp pain to the leftchest without radiation. The pain may occur with exercise orwhen the patient is at rest in a slouched position. The etiologyis unclear but is thought to occur from the parietal pleura,intercostals nerves or from the stretching ligaments of the heart.

Intense chest wall pain that follows a dermatome shouldraise the physician’s suspicion for a herpes zoster infection.

Diagnostic studies usually do not help identify muscu-loskeletal chest pain. If musculoskeletal pain is identified,

Work up History/symptom Sign

Chest radiograph Fever Tachypnea, rales and distress

Cough Ill appearing

Shortness of breath Tachycardia

Acute onset of pain Abnormal cardiac findings

Pain adversely affecting sleep Absent/decreased breath sounds

Associated with exercise Palpation of subcutaneous air

Associated with serious medical condition Drooling/gagging

History of foreign body ingestion

Electrocardiogram Pain precipitated exercise Abnormal cardiac findings

Syncope, palpitation Tachycardia (>180/min)

Drug use Ill appearing

Fever Fever

Underlying serious medical problems

Table 4 Worrisome signs andsymptoms to prompt furtherworkup in pediatric patients

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analgesics (ibuprofen or paracetamol) should be offered.The slipping rib syndrome can be treated with educationand avoidance of the offending movements. An orthopedicopinion is helpful as local nerve blocks and corticosteroidinjections are sometimes needed. A surgical alternative is tohave the anterior end of the rib and costal cartilageremoved, but this is usually done after failure of medicalmanagement. Precordial catch syndrome is a self limitingcondition that requires only education and supportive care.

Psychogenic

A psychogenic source for chest pain accounts for 5–9% ofED visits. Pediatric patients experiencing anxiety, depressionor stress can have symptoms manifesting as chest pain. Thehistory usually reveals a recent stressful event in the child oradolescents’ life. This could be school failure, recent death orillness in family, recent loss of friend frommoving to a new cityor school or school phobia. The family history may be positivefor angina, and the child may imitate the pain as an attentionseeking mechanism. The symptoms usually do not fit into anyspecific pattern. Play periods are not interrupted. Hyperventi-lation may be associated with psychogenic chest pain.Psychogenic chest pain should not be a diagnosis of exclusion.If significant stress is temporally related to the pain it is areasonable diagnosis. However, a concomitant cause for thechest pain should also be explored.

Idiopathic

Idiopathic chest pain is diagnosed in 12–61% of cases ofchildren with chest pain. A thorough history and physicalexamination is essential to look for a possible etiologybefore this diagnosis is made.

For patients with idiopathic or undiagnosed pain,analgesics and close follow-up are appropriate.

Management

Begin treatment directed at specific underlying etiology

& Bronchodilators for asthma-related pain

& Antibiotics for suspected pneumonia& H2 blocker or proton pump inhibitor for midsternal

burning pain& Analgesics for musculoskeletal pain& Management of traumatic chest/chest wall injuries

Treat idiopathic or undiagnosed pain

& Analgesics for all (paracetamol or ibuprofen unlesscontraindicated)

& Consider H2 blocker or proton pump inhibitor as atherapeutic trial.

Conflict of Interest None.

Role of Funding Source None.

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