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•Cathy S. Woodward, DNP, RN, PNP-AC

•Professor of Pediatrics

•UT Health -San Antonio

Chest Pain in Children: It's Not All Heart

Disclosures

• none

Objectives

•List the most common causes of benign chest pain in children.

•Discuss the differential for children presenting with acute chest pain.

•Describe the must-not-miss assessments in children with serious chest pain.

Chest Pain

Chest Pain Incidence of CP complaints

•3700 kids evaluated for CP only 1% related to cardiac cause.

•Musculoskeletal

•Pulmonary

•Gastrointestinal

•Anxiety

•Unknown cause

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Musculoskeletal CP

•Brief sharp chest pain

•Worse with deep breathing and movement

•History of trauma, fall, new exercise, cough

Musculoskeletal Causes of CP

•31% of children who see cardiologists

•Connective, bony and muscular tissue

•Precordial catch – short duration, unclear etiology

•Costochondritis

•Trauma

• Slipping rib syndrome

Slipping Rib Syndrome

•Described in 1919

•Hypermobility of ant ends of ribs 8-10

•Precipitating cause – cough, exercise, trauma

•Pain acute and is reproducible

•Hooking maneuver

Pulmonary Causes of CP

•Asthma

•Pneumonia/Pleuritis

•Chronic cough

•Pneumothorax

•Acute Chest Syndrome

Pneumothorax

•Chest Pain with SOB•Trauma or spontaneous•No breath sounds on affected side

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Acute Chest Syndrome

•Major cause of morbidity and mortality for children with Sickle Cell Disease – vasoocclusive crisis

•Pulmonary infiltrates, CP and fever, hypoxia

•Caused by embolism, bacterial or viral infections, asthma, lung infarct.

Gastrointestinal Causes of CP

•Esophageal reflux – burning pain, center of chest, pain increased or decreased by certain foods and body position

•Cholecystitis - rare

Psychological Causes of CP

•Preceding Stressful event

•Hyperventilation

•Depression

Non-Cardiac Chest Pain

•Push on chest - if pain is reproducible then not cardiac

•Pain increases with breathing or movement

•Brief CP

•Normal Vital signs

Serious Chest Pain

•Severe, unrelenting pain

•Fast heart rate

•Diaphoresis

•Fever

•SOB

•Recent illness

Cardiac Causes of CP

•Congenital heart disease

•Acquired heart disease

•Dysrhythmias

•Tumors

•Cardiomyopathy

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Congenital Heart Disease

•Left ventricular outflow obstruction –Aortic stenosis – CP with dizziness or fatigue

•Obstructive Lesions – Coarctation of Aorta

•Cyanotic Heart Disease – worsening hypoxia or dysrhythmias

•ALCAPA

Obstructive Lesions

•Decreased pulses in Left arm and lower legs.

•Cool extremities

•Hypertension

•Often dx during pre-sport physicals

Anomolous Left Coronary Aorta to Pulmonary Acquired Heart Disease

•Disease of the heart that develops after birth. •Affects heart muscle, heart valves or coronary arteries •Rheumatic Heart Disease – developing countries•Kawasaki Disease – developed countries•Myocarditis/Endocarditis•Cardiomyopathy

Acquired Heart Disease

•Rheumatic heart fever/disease•Rare in US • Immigrant population•Post strept pneumococcal pharyngitis•Autoimmune response to infection•Untreated infection

•Untreated fever leads to disease•Valvular disease

Prevention

•Untreated strep throat is the cause!•Most sore throats are caused by viruses NOT Strep.•Younger than 15 years•Fever•Tonsillar swelling or exudate•Tender anterior cervical nodes•No cough

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Diagnosis of Rheumatic Fever

• Jones Criteria – Major Criteria• Carditis• Arthritis• Subcutaneous Nodules• Chorea

• Rash – erythma marginatum

• Minor Criteria

• Fever• Leukocytosis – increase WBC• Elevated ESR or CRP• Recent Streptcoccal infection

Presence of TWO MAJOR or ONE MAJOR and TWO MINOR is enough to clinically diagnose rheumatic activity

Myocarditis/Endocarditis

•Serious, insidious viral or bacterial infections of the heart muscle and/or valves of heart

•Presenting Symptoms•Flu like – fatigue, malaise, fever•Chest pain, palpitations•Endocarditis - Splinter hemorrhages, Janeway nodules and Osler’s nodules

MyocarditisKawasaki Disease

• Leading cause of acquired heart disease in developed countries

•Acute febrile illness

•Vasculitis•Fever•Rash – erythema palms/soles, edema

hands•Bilateral conjunctival redness – no

exudate•Cracked lips, strawberry tongue•Cervical lymphadenopathy

Kawasaki DiseaseCardiac Tumor

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Cardiomyopathy

•Dilated - muscle fibers weak and unable to contract

•Hypertrophic – thickened and stiff ventricles can’t fill or contract

•Restrictive – normal contraction, ineffective relaxation

Dysrhythmias

•Irritable focus – children with hx of heart disease

•Fever

•Stimulants•Caffeine•Cocaine

Dysrhythmias

• Rapid Tachycardias

Case Study

•8 yr old with hx of CHD

•Walking in hall at school and had sudden onset of CP and SOB

•Sternal Scar

8 yr old with CP Assessment of Child with CP

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History

•Is pain new

•How often does it occur

•Where is pain

•Quality – sharp, dull, squeezing

•Radiation of pain

•What makes it better or worse

•Associated symptoms

•Fainting? Dizziness?

History

•Fatigue

•SOB

•Pain worse with breathing?

•Worse in different position?

•Exercise make it worse?

•Anyone else in family with chest pain?

•Recent stresses in your life

•Medications?

Cardiac Questions

Have you ever passed out or nearly passed out during or after exercise?

Have you ever had discomfort, pain, or pressure in your chest during exercise?

Does your heart race or skip beats during exercise?

Does anyone in your family have heart problems or Marfan’s?

Has a doctor ever ordered a test for your heart (e.g., electrocardiography, echocardiography)?

Has anyone in your family died for no apparent reason?

Has anyone in your family died of heart problems or of unexplained sudden death before age 50?

Physical Assessment

•Chest wall – PMI and abnormalitiesApical impulse

< 7 yrs 4ICS just left of midclavicular line > 7 yrs 5ICS midclavicular linePMI laterally or downward – vent hypertrophy

PMI – RV dominance LLSB or xiphoid –Heaves – impulse diffuse and slow rising - voloverload Tap – localized and sharp – pressure overload

Precordial bulge – chronic cardiac enlargement

Physical Assessment

• Pulses and BP• Rate• Presence of pulse in all extremities

• Weak or non-existent pulses in legs with strong arm pulses suggest COA – take blood pressures

• Bounding pulses – run off lesions • Pulsus paradoxus – greater than 10 mmHg

difference during inspiration – pericardial effusion, cardiac tampanode, severe respdistress.

• FEVER

Physical Assessment - Murmurs

•If murmur becomes Softer with Squatting

•OR Louder or Longer with standing or during valsalva•Think hypertrophic cardiomyopathy or mitral valve prolapse

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Case Study

•15 year old, male, c/o chest pain “10”

•Denies SOB, N/V

•Hx of SVT

•Cough and nasal congestion last three days

•No fever

•Meds: Digoxin, mucinex for allergies

15 yr old with CP

Treatment with Adenosine Case Study

•15 year old female

•C/o fatigue and chest pain x 3 days

•Hx – viral type respiratory illness two weeks ago

•HR 115 BP 90/50 RR 14 T 98.8

Case Study

•16 year old

•Fever for three days and CP starting this am

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What to do while waiting for Ambulance

•If ill appearing, abnormal vital signs or change in LOC – apply oxygen

•Keep NPO

•AED in the room

•If hx of SVT – vagal maneuvers

Chest Pain in Children

•Most often not emergent or serious•Consider more serious if CP associated with•Fever•SOB•Fast heart rate•Diaphoresis•Recent Illness

Chest Pain in Children: It's Not All Heart

woodwardc@uthscsa.edu

Questions?