Clinical Practice Guidelines

Chest pain

    Background

    The majority of children presenting with chest pain as a primary complaint do not have a cardiac or other serious underlying disorder.  The priorities of assessment are to firstly exclude these disorders or provide appropriate emergency treatment and to subsequently form a diagnosis and management plan for the remainder of cases.  Common causes of paediatric chest pain in patients without risk factors for serious disease include:

    • Musculoskeletal strains
    • Respiratory infections with or without cough
    • Asthma exacerbations
    • Upper GI or biliary disease
    • Precordial "catch" - sudden short sharp pains experienced, often on left side of chest, usually in healthy teenagers and young adults. The origin of this pain is unknown.
    • Anxiety, idiopathic - many children have no organic diagnosis made.

    The presence of certain risk factors increases the probability of potentially serious causes.

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    Risk factors for serious or life threatening conditions

    Risk factor   Condition to consider
    Major chest trauma Pneumothorax, haemothorax, cardiac or pulmonary contusion, mediastinal disruption.
    Prior cardiac disease or surgery Myocardial ischaemia, arrhythmia, pericarditis, pericardial effusion.
    Hypercoaguable states
    (primary clotting disorders, neoplasms, pregnancy, contraceptive pill use, prolonged immobility or post surgery,cental venous catheters, connective tissue disease, past history or strong family history of thromboembolic disease)
    Pulmonary embolus
    Sickle cell disease Acute chest syndrome
    Chronic respiratory disease Pneumothorax
    Kawasaki disease Coronary aneurysm and myocardial ischaemia
    Familial hyperlipidaemia syndromes Myocardial ischaemia
    Cocaine or stimulant use Myocardial ischaemia
    Connective tissue disease Pericarditis and pericardial effusion, aortic dissection

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    Assessment

    The most important step in initial assessment is identifying signs of cardiorespiratory distress:

    • Dyspnoea, tachypnoea, increased work of breathing
    • Hypoxia
    • Abnormal pulse or blood pressure
    • Poor perfusion
    • Distended neck veins, muffled heart sounds
    • Depressed mental state

    For further specific assessment of underlying cause see chest pain flowchart

    Key examination and basic investigation findings that may be identified in uncommon serious conditions are presented in the table below:

    Condition  Findings
    Myocardial ischaemia Abnormal pulse or blood pressure, arrhythmia, ST segment elevation or depression, raised troponins
    Pericarditis  Positional pain, pericardial rub, widespread 'saddle-shaped' ST elevation
    Pericardial effusion Hypotension, distended neck veins, muffled heart sounds, pulsus paradoxus, globular enlarged cardiac silhouette on CXR
    Pulmonary embolus Tachypnoea, tachycardia, hypoxia, haemoptysis, non specific ST and T wave changes in anterior chest leads most common ECG finding, 'classical' S1Q3T3 pattern is uncommon.  May see minor CXR abnormalities - usually normal
    Aortic dissection   Differential limb BP's, CXR findings include: widened mediastinum, left pleural cap and deviated trachea and main stem bronchi.  Signs of myocardial ischaemia or pericardial tamponade if complicated by these events. 

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    Management

    • Trauma patients and those with signs of cardiorespiratory compromise should be resuscitated along general principles prior to considering more directed management (see resuscitation guideline).
    • The chest pain flowchart provides a guide for further management including special investigations, consultation and referral.
    • All patients with positive risk factors for serious conditions should be discussed with senior staff prior to final disposition.
    • Despite the rarity of serious underlying conditions, many children and parents have significant anxiety surrounding possible cardiac disease.  Specific reassurance is an important part of management.

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    Paediatric chest pain

    Paediatric chest pain

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