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.

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

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 below.

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.

Management

Trauma patients and those with signs of cardiorespiratory compromise should be resuscitated along general principles prior to considering more directed management (see resuscitation).
The flowchart below 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.

Paediatric chest pain

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The Royal Children's Hospital Melbourne

Clinical Practice Guidelines