Chest Pain In Children and Adolescents Caroline L. Derrick BSN, RN University of Michigan

Most causes are Benign Common Complaint from Children in ER Known association with myocardial infarction (MI) and sudden death in adults In children, Cardiac causes are the least likely in association with presenting chest pain. 9/18/2018

Studies Nurse Practitioner Study: 50 Children with CP referred to Pediatric Cardiologist- non-cardiac cause. 3/1,000 children visiting ER for CP, only 1% were cardiac in nature LT outcomes in idiopathic CP- 81% reported no CP after 3 year follow up. 9/18/2018

Differential Diagnosis Musculoskeletal Respiratory GI Idiopathic Psychogenic Cardiac 9/18/2018

Musculoskeletal Pain Muscle Strain: Chest wall pain- usually associated with strain of muscles and may occur with excessive exercise or trauma. Strain of the upper back or pectoral muscles Direct trauma to the chest- athletics, accidents, physical abuse. Trauma may include rib fractures, intercostal muscle strain, pneumothorax or hemothorax. 9/18/2018

Costochondritis 10-22% Childhood CP Local, sharp pain in the mid-sternal area Reproducible pain with palpation along costochondral margins May last for several months More common in girls Treatment: Reassurance, NSAIDS, rest 9/18/2018

Slipping Rib Syndrome Sprain disorder r/t trauma to 8th, 9th, 10th ribs Sensation of ribs “slipping” Pain with flexing the trunk, turning over, deep breathing, prolonged walking, coughing Positive “hooking maneuver” Treatment: reassurance, injection of local anesthetic, possible surgical removal of affected cartilage. 9/18/2018

Respiratory Causes Pneumonia and Asthma may cause excessive coughing, may continue to overuse chest wall muscles. Pleural Effusions- pain exaggerated by deep breathing Pneumothorax- Chest pain Tachypnea, retractions, wheezing, fever, decreased breath sounds. CXR, SpO2%, peak flow meter levels 9/18/2018

Gastrointestinal Pain 2-7% of all causes of CP in adolescents Esophagitis/GERD- “burning”, aggravated in a reclined position. Pain with eating meals or spicy foods Foreign body ingestion- toddlers; lodged in proximal esophagus Caustic Ingestions- household cleaners- damage to esophagus *** Bulimia Nervosa- purging- esophagitis/ perforation. 9/18/2018

Idiopathic CP Most common cause of childhood/adolescent CP No organic or psychogenic cause after thorough history, PE, labs Emotional stress/Anxiety, especially in girls Hyperventilation Syndrome- hypercapnic alkalosis. Associated with lightheadedness, HA and parasthesias 9/18/2018

Rare Causes of CP Thoracic tumor Sickle Cell Disease Herpes Zoster Ectopic Pregnancy Precordial Catch- Texidor’s Twinge- Syndrome associated with CP. Described as brief (less than 5 minutes), sharp, shooting, left sided pain Pain subsides with shallow breathing and straightened position Thought to be produced by pressure on intercoastal nerve 9/18/2018

Cardiac Causes of CP- Congenital Anomalies Mitral Valve Prolapse(MVP) Most prevalent cardiac lesion associated with CP in children/adolescence Associated with thickening of mitral valve leaflets- bulge into the annulus. Pain results from Left ventricular endocardial ischemia as the valve prolapses 30% of MVP patients report CP Mid-systolic ejection “click” Systolic ejection murmur id regurgitation is present 9/18/2018

Cardiac causes of CP- Congenital Anomalies Left ventricular outflow obstruction- group of lesions that produce a significant risk for ischemic myocardial dysfunction. Aortic Stenosis (AS) common- progressive over time- associated with bicuspid aortic valve Causes a decrease in CO CP with exertion PE- systolic ejection click, systolic murmur over aortic valve region and palpable thrill at suprasternal notch Aortic Stenosis Murmurs become louder when going from standing to squatting. EKG- hypertrophy patterns may be present 9/18/2018

Cardiac causes of CP- Congenital Anomalies Subaortic Stenosis/ IHSS- obstructive lesions also associated with CP with exercise and exertion. Harsh systolic murmor heard from squatting to standing. IHSS inherited lesion- autosomal dominant pattern 9/18/2018

Cardiac causes of CP- Congenital Anomalies Anomalous Origin of the Left Coronary Artery- rare Limited coronary artery blood flow, causing ischemia Angina type pain, syncope PE- Pan systolic continuous or mitral regurgitant murmur may be heard as well as a gallop. 9/18/2018

Acquired Conditions Pericarditis- infectious process causing inflammation of the pericardium Sharp, shooting pain Precordial in location Often relieved by leaning forward Cough fever, respiratory distress may be present PE- heart sounds may be distant, muffled; a rub may be auscultated Rub may disappear with development of pericardial effusion EKG: ST segment or T wave change 9/18/2018

Acquired Conditions Kawasaki Disease- a history of this disease with coronary artery involvement, presenting with CP should be considered for myocardial ischemia. Immunoglobulin treatment- without 20-25% children have coronary artery involvement at the time of presentation. If administered within 10 days, incidence falls from 3-5% Children with coronary artery abnormalities almost always have left ventricular hypertrophy EKG: Abnormal ST segment or inverted T waves are noted in precordial leads. 9/18/2018

Acquired Conditions Cardiomyopathy- general term used to describe ventricular dysfunction Many types- only some present with CP Fatigue, decreased exercise tolerance, palpitations Dilated Cardiomyopathy may have CP with exertion and a systolic murmur. Ask about a familial history of sudden cardiac death when a child has dilated cardiomyopathy. 9/18/2018

Acquired Conditions Myocarditis preceded by viral illness Children may have a fever, malaise, nonspecific CP, respiratory distress. PE- may produce evidence of a gallop Chest radiograph- cardiomegaly ECG- ST segment depression and T wave abnormalities 9/18/2018

Arrhythmias SVT (Supraventricular tachycardia)- may cause CP. Most common childhood arrhythmia Rapid heartbeat>200 bpm PE: diaphoresis, pallor, hypotension, syncope Can convert to SR with vagal Stimulation Frequent episodes of syncope, treatment options include: pharmacologic therapy (Adenosine) or ablation 9/18/2018

Arrhythmias Ventricular Tachycardia (VT)- rare but associated with CP Wide complex tachycardia Rate 120-140 bpm Medical Emergency- may progress to Ventricular fibrillation Causes: viral myocarditis, surgically induced sequelae or prolonged QT interval. 9/18/2018

Questions to Ask: Past Medical History History of: asthma, sickle cell disease, rhematic fever, cystic fibrosis?- CP may indicate a complication. History of congenital or acquired heart disease? Even if it was fixed may produce CP. 9/18/2018

Severity of CP Scale “0-10” or smiley faces Worst pain ever? Interfere with daily activities? What makes the pain better? Worse? Any associated factors related to the chest pain? Organic vs. Psychogenic pain 9/18/2018

Onset, Frequency, Duration When did the pain start? What were you doing when the pain started? How often does the pain occur? When does the pain occur? What activities are you doing? How long does the pain last, is it continuous or does it come and go (intermittent)? How long has this been going on? 9/18/2018

Type and Location How would you describe the pain? Sharp, dull, burning, pressure, etc? Sharp pain- costochondritis, musculoskeletal, may be located along costochondrial junction Burning- espohagitis, indigestion, may be located at midsternal area. Where is the pain located, does the pain radiate (travel) to any other areas? (jaw, neck, shoulders, abdomen, arm, etc.) Sharp pain that radiates to the neck, back and shoulders may be associated with pneumomediastinum 9/18/2018

Associated Symptoms Palpitations Dizziness Syncope with CP *** These symptoms are associated with cardiac causes of CP and should be taken seriously Recent Flu like symptoms, prolonged fever with new onset of CP- endo, pericarditis, myocarditis- immediate work-up required 9/18/2018

Precipitating Factors Anxiety- explore recent events- new school?, etc. Tend to complain of CP during the week but not on weekends, holiday breaks or summer. 9/18/2018

Family Events Ill family member? Divorce? Physical or sexual abuse? Girls: BCP- rare Pulmonary embolism Depression- stressors 9/18/2018

Family History Pivotal History of acquired or congenital heart disease, Marfan Syndrome or history of arrhythmia Critical- history of sudden cardiac death in a family member Idiopathic hypertrophic subaortic stenosis- autosomal dominant disorder associated with sudden cardiac death. 9/18/2018

Physical Exam Complete Signs of severe distress, pain, anxiety Vital signs,BP and weight within range for age? Assess respiratory function for distress or abnormalities Ecchymosis, trauma, rash, chest heave, abnormal shape of chest, scoliosis or syndromic appearance. Tall and thin with long fingers and toes? (Marfan Syndrome) 9/18/2018

Physical Exam Palpate chest wall to attempt to reproduce or locate source of CP Include clavicals, entire chest wall, breasts and zyphoid area Assess for palpable thrill or RV heave- both consistent with congenital and acquired heart disease Subcutaneous emphysema- trauma or spontaneous pheumothorax? Palpate abdomen- tenderness and assess for hepatosplenomegaly 9/18/2018

Physical Exam Palpate extremities for warmth and general perfusion Assess pulses in all four extremities for equality and strength Hooking maneuver Auscultate the heart for murmurs, gallops, rubs, dysrhythmias and any other abnormal heart sounds Auscultate in supine, sitting , standing and squatting positions- helps to hear murmurs of AS and sub AS. Lie patient on left side- assess for murmur of mitral regurgitation or mitral valve click Auscultate all lung fields assess for wheezes, rales, or asymmetry of breath sounds 9/18/2018

Further Evaluation Labs usually not needed In most cases, H& P will clarify cause Consider peak flow meter if asthma may be the cause Order CXR if signs of pleural effusion, pneumothorax, pneumonia, chest trauma, or bone fracture Consider pregnancy test 12 lead ECG Holter Monitors, journal/diary Journal/diary of events surrounding CP Exercise Stress Testing- cardiac rhythm during exercise Referral if cardiac in origin 9/18/2018

Good Prognosis CP in children/adolescents common and rarely cardiac related Thorough H & P essential to rule out rare and life threatening causes of CP Most causes of CP are benign and cause no further sequelae. 9/18/2018