Download Pediatric Chest Pain

PEDIATRIC
CHEST PAIN
EMS REGION 8
J A N U A RY 2 0 1 7 C E
OBJECTIVES
• Discuss the most common causes of chest pain in pediatric patients
• Differentiate cardiac from non cardiac chest pain
• Discuss evaluation of the pediatric patient who has chest pain
INTRODUCTION
1.
SME video of the month: Dr. Mark Cichon
2.
Review of Pediatric Cardiac SOPs
3.
Scenarios
DR. CICHON VIDEO
• January 2017 CE final
PEDIATRIC CHEST PAIN
• One of the most common reasons for a child to visit a pediatrician or
the Emergency Department
• Various disorders may cause chest pain in children and adolescents
– Cardiac
– Gastrointestinal
– Respiratory
– Psychogenic
– Idiopathic
PEDIATRIC CHEST PAIN
• Pediatric chest pain is classified into cardiac or non cardiac chest pain
• Most episodes of chest pain in children have non cardiac causes
• Good history taking and physical exam are important
• Be suspicious if child is colicky, has palpitations, light headedness,
syncope, seizure or exertional symptoms
PEDIATRIC CHEST PAIN
• Age is a consideration when assessing chest pain in a child
• Young children may interpret a wide range of symptoms or chest
sensations as pain
• Adolescents are more likely to have musculoskeletal or psychogenic
causes
NON-CARDIAC CHEST PAIN
• Causes of non-cardiac chest pain
– Musculoskeletal
– Costochondritis
– Tietze syndrome
– Non-specific or idiopathic chest wall pain
– Slipping rib syndrome
– Trauma or muscle overuse
– Xiphoid pain
– Sickle cell vaso-occulsive crisis
NON-CARDIAC CHEST PAIN
• Pulmonary or airway related causes
– Asthma
– Bronchitis
– Pleuritis
– Pneumonia
– Pulmonary embolism
– Pneumothorax
– Acute chest syndrome
NON-CARDIAC CHEST PAIN
• Gastrointestinal causes
– Gastroesophageal reflux
– Esophageal spasm
– Peptic ulcer disease
– Drug induced esophagitis/gastritis
– Cholecystitis
NON-CARDIAC CHEST PAIN
• Miscellaneous causes
– Panic disorder
– Hyperventilation
MUSCULOSKELETAL PAIN
• AKA chest wall pain
• The most common cause of chest pain
in children and adolescents
• The prevalence is between 15% and
31%
COSTOCHONDRITIS
• Common cause of chest pain in children and adolescents
• Inflammatory process of one or more costochondral cartilages
• Causes localized tenderness and pain of the anterior chest wall
COSTOCHONDRITIS
• Unilateral, sharp, stabbing pain
• Occurs along the upper two or more contiguous costochondral joints
• Exacerbated by deep breathing
• Pain lasts for a few seconds to a few minutes
• Chest wall tenderness can be reproduced by palpation over the
affected area
COSTOCHONDRITIS
• Most cases are idiopathic
• Other causes
– Costochondral irritation due to trauma
– Aggressive exercise resulting in strain of the costochondral cartilage
– Prior upper respiratory tract infection with cough causing stretching and
strain to the cartilage, resulting in local irritation and pain
• Cartilage involved is either inflamed or fractured
TIETZE SYNDROME
• First described in 1921 by German surgeon Alexander Tietze
• Rare inflammatory disorder
• Specific inflammation of the first two or three costochondral
articulations
TIETZE SYNDROME
• Chest pain and swelling of the cartilage of one or more of the upper
ribs
• Specifically where the ribs attach to the sternum
• Usually characterized by involvement of a single joint along with signs
of inflammation such as warmth, swelling, tenderness
TIETZE SYNDROME
• May be aggravated by sneezing,
coughing, deep inspiration, or a
twisting motion
• Onset of pain may be gradual
or sudden
• Pain may spread to affect the
arms and/or shoulders
• Mimics cardiac pain
SLIPPING-RIB SYNDROME
• Also known as lower rib pain syndrome
• Occurs infrequently in children
• Characterized by intense pain in the lower chest or upper abdominal
area
• Caused by trauma or dislocation of the 8th, 9th and 10th ribs
• Impinges on the intercostal nerves
Slipping Rib
Syndrome
SLIPPING-RIB SYNDROME
• Pain can be
reproduced by
the “hooking
maneuver”
– Fingers are
placed under
the inferior rib
margin and pulls
the rib edge
outward and
upward
PRECORDIAL CATCH
SYNDROME
• AKA Texidor’s twinge
• Affects children more than
adults
• Most commonly affects
children aged 6-12 years
• Characterized by sudden,
sharp and localized chest pains
lasting a few seconds to a few
minutes along the lower left
sternal border
• Pain usually occurs while at
rest
• Most common sites for pain:
left sternal border, right
anterior chest, flanks
PRECORDIAL CATCH
SYNDROME
• Cause is unknown, but not cardiac or pericardial in nature
• Has been associated with poor posture and may be caused by a
pinched nerve
• Exacerbated with inspiration, often leading to shallow breathing in an
effort to alleviate pain
XIPHODYNIA
• AKA hypersensitive xiphoid syndrome
• Musculoskeletal disorder capable of producing symptoms that mimic
several common abdominal and thoracic diseases
• Pain or discomfort is localized over xiphoid process of the sternum
XIPHODYNIA
• May be exacerbated by eating
a heavy meal, coughing and
bending or rotating
movements
• Cause is unknown
• Compression of the xiphoid
process can reproduce the
pain
XIPHODYNIA
• Symptoms include:
 Cardiac chest pain
 Epigastric pain
 Nausea vomiting, diarrhea
 Pain radiating into the back, neck, shoulders, arms and chest wall
• Treatment is analgesics, topical heat and cold or an injection of local
anesthetic and steroids
PECTUS
EXCAVATUM
• Also known as funnel chest
• Occurs in one in 300-400 births
• Affects males 3:1
• Congenital chest wall deformity where
the cartilage that holds the ribs to the
breastbone grows abnormally and
pushes the breastbone inward so the
chest looks sunken
• Unknown cause
PECTUS EXCAVATUM
• Appearance varies widely from mild to severe
with significant asymmetry between sides
• Maybe noticed at birth with progressive
worsening as the child grows
• Chest pain is a frequent symptom
• Moderate-to-severe cases:
• Shortness of breath
• Chest pain
• Exercise intolerance
PECTUS EXCAVATUM
• Surgical repair is rarely
needed
SCENARIO
• You are called to the local pre-school for the 4-year-old complaining
of pain. When asked where it hurts, she points to her right chest along
the rib cage. Teacher informs you the girl just returned to school after
being out for several days with viral respiratory illness.
SCENARIO
• S- when asked to take a deep breath,\ she cries and
says it hurts
• A- none known
• M- ibuprofen for fever
• P- Viral respiratory illness
• L- breakfast
• E- Playing with other kids on playground and
complained of pain
SCENARIO
• Vital signs:
– Pulse 98
– BP 100/60
– RR 24, shallow
– SpO2 95% on RA
• Skin warm, flushed, dry
• Breath sounds diminished on right side
• Treatment?
• Possible causes
PULMONARY CAUSES
• Prevalence of chest pain due to respiratory causes is about 2-11%
• Pneumonia and asthma are common causes of acute pediatric chest
pain
• Exercise induced asthma frequently causes chest pain in the pediatric
population
• Any respiratory condition with chronic cough may also cause chest
pain due to muscle strain
PLEURODYNIA
• Acute illness with marked paroxysmal spasms of the muscles of the
chest and abdomen
• Acute onset of pain
• Pain is severe, intense and excruciating, lasting seconds to a minute
• Severe attacks can cause difficulty in breathing
• Thoracic pain occurs over lower ribs and is unilateral
PLEURODYNIA
• Pain can also occur over front, back and substernal area
• Between attacks, child may have constant dull pleuritic pain
• Persists for about 5 days
• Associated with symptoms related to a viral infection (URI)
EXERCISE-INDUCED ASTHMA
• Most common pulmonary cause of chest pain
• AKA exercise induced bronchoconstriction
• Frequently results in chest pain
• Caused by loss of heat and/or water from lungs during exercise
EXERCISE-INDUCED ASTHMA
• Dryness of the air, rather than the temperature, is the most likely
trigger
• Quickly breathing dry air dehydrates the bronchial tubes, causing
them to narrow and restrict airflow
EXERCISE-INDUCED ASTHMA
• 90% of people with asthma have EIB but not everyone with EIB has
asthma
• Common symptoms include:
 Shortness of breath or wheezing
 Decreased endurance
 Chest tightness or pain
 Cough
 Sore throat
SPONTANEOUS
PNEUMOMEDIASTINUM
• Presence of gas in the
mediastinum in the
absence of trauma
• Caused by alveolar
rupture and
dissection of air into
the mediastinum
SPONTANEOUS
PNEUMOMEDIASTINUM
• Initial peak in incidence during late infancy and early childhood due to
high prevalence of respiratory infections in this age group
• Thought to be caused by increased pressure within obstructed
airways
• Second peak during adolescence:
– Tall, thin males
SPONTANEOUS
PNEUMOMEDIASTINUM
• Approximately 25-90% of children with SPM present with chest pain
• Pain is retrosternal and pleuritic in nature
• Presence of subcutaneous emphysema
• Pain increases during deep inspiration and dyspnea
• Pain may radiate to neck, shoulders, and arms
SPONTANEOUS
PNEUMOMEDIASTINUM
• Can occur in the presence of:
– acute asthma
– respiratory tract infections
– vigorous vomiting or
coughing
– intense physical effort
– illicit drug use
– Valsalva maneuver
SPONTANEOUS
PNEUMOMEDIASTINUM
• Uncomplicated SPM is treated conservatively with analgesia, rest and
avoidance of maneuvers than increase pulmonary pressure
• Usually resolves within 2-15 days and rarely reoccurs
PLEURISY
• Inflammation of the
pleura
• Occurs when the two
layers of the pleura
become red and
inflamed, rubbing against
each other with lung
expansion
• Sharp, stabbing pain in
chest that worsens with
deep breathing,
coughing or sneezing
PLEURISY
• Symptoms usually occur on one side of the chest
• May extend to shoulder and belly
• Eases when you hold your breath or press on the painful area
• Treatment depends on the cause
SCENARIO
• Called for the 5-year-old male in acute respiratory distress. Upon
arrival parents rush you into bedroom to find the patient
unresponsive and apneic.
• Your crew begins resuscitation while you gather additional
information.
SCENARIO
S- Difficulty breathing then unresponsive
A- Penicillin
M- Tylenol with Codeine for pain
P- Cerebral palsy. Surgery 2 weeks ago for tendon lengthening.
Bilateral casts
• L- Breakfast
• E- Patient has been home from hospital for 4 days with nursing
and physical therapy coming twice daily. Pain was sudden onset
upon waking up this morning when patient’s position was
changed.
•
•
•
•
SCENARIO
• Vital signs:
– Pulse: Absent
– Respirations: Absent
– BP: N/A
– Oxygen saturation at 70%
• What are your next steps?
• Possible causes?
PULMONARY EMBOLISM
• Rare in pediatric population and may not be considered as cause
• Risk factors
– Obesity
– Immobility
– Central venous catheters
– Malignancy
– Congenital heart disease
– Lupus
– Recent surgery or trauma
PULMONARY EMBOLISM
• Non-specific symptoms
– Tachypnea
– Tachycardia
– Fever
– Pleuritic chest pain
– Shortness of breath
GI CAUSES OF CHEST PAIN
• Prevalence of chest pain due to gastrointestinal causes is about 8%
• Common causes:
– Gastroesophageal reflux
– Peptic ulcer disease
– Esophageal spasm
– Cholecystitis
– Drug-induced esophagitis
GI CAUSES OF CHEST PAIN
• Symptoms
– Pain often recurrent or epigastric but may also be mid sternal
– Typically burning or sharp in nature
– May be exacerbated with eating or posture
– Can be associated with heartburn, water brash or dysphagia
DRUG-INDUCED
ESOPHAGITIS
• Occurs in pediatric patients treated with tablets or capsules
• Esophagitis most frequent esophageal disorder in children
• 90% occurs after use of NSAIDS or antibiotics
• Symptoms include chest pain, dysphagia and retrosternal pain
• Usually self-limiting
PSYCHOGENIC
• Psychogenic chest pain in older children can result from anxiety or a
conversion disorder triggered by recent stressors in personal or
family life
• Approximately 1/3 of adolescents complaining of chest pain had a
history of stressful events either in family or at school
PSYCHOGENIC
• Often recurrent with particular stressors
• History of anxiety or panic disorders and/or stressful life events
• May be associated with hyperventilation
• This may accompanied by difficulty in breathing, dizziness, paresthesias
and chest pain
PSYCHOGENIC
• Hyperventilation due to anxiety or a panic disorder can cause chest
pain
• May be accompanied by difficulty in breathing, dizziness or paresthesia
CARDIAC CAUSES OF CHEST
PAIN
• Chest pain due to a cardiac condition is rare
• Infectious or inflammatory
– Pericarditis: inflammation of the sac surrounding the heart
– Myocarditis: a viral infection of the heart
– Endocarditis: infection of inner lining of the heart
• Coronary artery and structural abnormalities
• Dissection, or tearing, of the aorta
PERICARDITIS
• Inflammation of the heart lining
• Usually infectious
• Sharp retrosternal chest pain
that often radiates to the left
shoulder
• Pain increases when patient lies
supine or takes a deep breath
• Pain is relieved by bending
forward
• May have low grade fever,
irritability, fatigue
ACUTE CHEST SYNDROME
• Most common cause of sickle cell-related death
• Second most common cause of hospitalizations in patients with sickle
cell disease
• Recurrent ACS events have been associated with chronic lung disease
and early death
ACUTE
CHEST
SYNDROME
• Defined as presence
of a new pulmonary
infiltrate
• Symptoms include:
 Fever
 Chest Pain
 Respiratory distress
 New onset hypoxemia
ACUTE CHEST SYNDROME
• Higher occurrence in winter months
• Children more likely to have preceding febrile events
• Peak incidence between ages of 2 and 4 years
• Rarely seen in children < 2 years
• Respiratory infections leading cause of ACS
MARFAN SYNDROME
• Genetic connective tissue disorder
• Affects 1 in 5,000
• Male and female of all races and ethnic groups
• 3 out of 4 people inherit it
• Severity of condition varies
• Features and related disorders can appear at any age
MARFAN SYNDROME
• Additional signs
– Heart problems especially those related to the aorta, mitral valve
prolapse, and mitral regurgitation, heart murmur, arrhythmias
– Chest pain when active
– Sudden lung collapse
– Eye problems including severe nearsightedness
MARFAN SYNDROME
• Requires individualized treatment plan depending on structures
affected and severity
• Medications typically not used to treat
• If aorta affected, beta blockers may be utilized to prevent or slow the
enlargement
• Goal to prevent aortic dissection or rupture
MARFAN
SYNDROME
• Aortic dissection
– Tear or rupture
between the layers
of the aortic wall
– Ascending aortic
dissection is most
common (1)
– Sharp, tearing pain
or ripping
sensation to the
back or shoulders
TACHARRHYTHMIAS
• Supraventricular tachycardia
• Wolff-Parkinson-White syndrome
• Ventricular tachycardia
• Symptoms may be mild or severe
WOLFF-PARKINSON-WHITE
• Extra electrical
pathway in the heart
• One of the most
common causes of
tachycardia in infants
and children
• HR >100 bpm and
<150 in newborns,
infants and small
children
• Blood pressure is
usually normal or low
WOLFF-PARKINSON-WHITE
• Symptoms
– Feeling faint, weak, light
headed or dizzy
– Shortness of breath
– Chest Pain
– Syncope
– Irritability
– Pallor
– Poor feeding (infants)
WOLFF-PARKINSON-WHITE
PULSE
OXIMETRY
SKILL OF THE MONTH
PULSE OXIMETRY
• Pediatric Pulse Oximetry
– Normal SpO2 is 96-98%
– SpO2 < 95% is considered abnormally low and requires evaluation
• Several conditions may affect accuracy of SpO2 readings
• Technique is important for accuracy in pediatric patients
PULSE OXIMETRY
Patient Considerations Affecting Pulse Oximetry Accuracy
Carboxyhemoglobin
•
CO has 200-250 greater affinity for Hgb molecule than O2 and
binds to same sites
Carboxyhemoglobin cannot be distinguished by SpO2 from
oxyhemoglobin
Smoke inhalation, cigarette smoking/exposure or CO poisoning
Anemia
•
•
Low quantity of RBCs or hemoglobin
Consider with various forms of anemia or bleeding conditions
Hypovolemia/
hypotension
•
•
Adequate O2 saturation but reduced O2 carrying capacity
Vasoconstriction or decreased CO may result in loss of
detectable pulsatile waveform
Patients in shock or those on vasoconstrictors (dopamine) may
not have adequate perfusion to be detected by SpO2
•
•
•
Hypothermia
•
•
Severe peripheral vasoconstriction may prevent SpO2 detection
Shivering may result in erroneous readings
PULSE OXIMETRY
Patient Environments Affecting Pulse Oximetry Accuracy
Ambient light
•
•
•
Motion
•
External light exposure to vascular bed may result in erroneous
reading
Single-use sensors may not prevent light passing through sensor
Shield the sensor from bright lights, such as in patient
compartment of ambulance
Pulse rate must coincide with palpated pulse rate
Other Problems Affecting Pulse Oximetry Accuracy
Fingernail polish,
pressed on nails
•
•
Remove fingernail polish that contains metallic flakes
Place SpO2 sensor on ear if suspected erroneous readings
Skin pigmentation
•
Apply sensor to fingertip in darkly pigmented patients
PULSE OXIMETRY
• Alternative sites
– Disposable sensors
• Ear lobe
• Arm or leg
• Forehead
• Hand or foot
– Reusable clip sensor
• Upper portion of ear
• Great toe
– Frequently assess site for skin
integrity, warmth, redness, and
neuromuscular status (CMS)
PULSE OXIMETRY
• Adverse effects: thermal burns
– Higher risk with decreased
blood flow to area where
sensor is applied
– Use caution with shock,
hypothermia, ischemia to
extremity
– Toes, fingers have thinner skin
– Infants (and elderly) have more
friable/fragile skin and poor
peripheral perfusion
PULSE
OXIMETRY
• Adverse effects: thermal
burns
– Compression of skin
by sensor my
decrease blood flow
– Patients unable to
communicate or
perceive noxious
stimuli (skin heating)
– Use of adult probe
on infants, neonates
QUESTIONS?