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Chest pain in children Slide 1 Chest pain in children Slide 2 Chest pain in children Slide 3 Chest pain in children Slide 4 Chest pain in children Slide 5 Chest pain in children Slide 6 Chest pain in children Slide 7 Chest pain in children Slide 8 Chest pain in children Slide 9 Chest pain in children Slide 10 Chest pain in children Slide 11 Chest pain in children Slide 12 Chest pain in children Slide 13 Chest pain in children Slide 14 Chest pain in children Slide 15 Chest pain in children Slide 16 Chest pain in children Slide 17 Chest pain in children Slide 18 Chest pain in children Slide 19 Chest pain in children Slide 20 Chest pain in children Slide 21 Chest pain in children Slide 22 Chest pain in children Slide 23 Chest pain in children Slide 24 Chest pain in children Slide 25 Chest pain in children Slide 26 Chest pain in children Slide 27 Chest pain in children Slide 28 Chest pain in children Slide 29 Chest pain in children Slide 30 Chest pain in children Slide 31 Chest pain in children Slide 32 Chest pain in children Slide 33 Chest pain in children Slide 34
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Chest pain in children

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Chest pain in children

Chest pain in children

  1. 1. Chest pain • Chest pain is common in children and adolescents. • Despite the degree of concern that it generates, the symptom is rarely associated with a serious cardiac problem. • The epidemiology of chest pain in youth is not well understood, although available data suggest more cases are classified as idiopathic than are attributed to a more specific etiology (e.g., cardiac, respiratory). • Studies approximate between 1% and 10% of pediatric chest pain cases are due to cardiac etiologies.
  2. 2. history and physical Examination • A properly done history and physical are often the only tools required in the evaluation of pediatric chest pain. • Screening tests are not considered helpful unless specifically indicated. • Eliciting the patient’s or family’s concerns about their complaint may be useful.
  3. 3. • A medical history of asthma, sickle cell disease, collagen vascular disease, or a recent coughing illness may be helpful. • Long-standing diabetes mellitus and chronic anemias are risk factors for ischemic chest pain. • Inquire about a history of Kawasaki disease, including the possibility of an undiagnosed case. • The review of systems should include inquiries about associated acute and chronic symptoms and any precipitating factors. History
  4. 4. • Inquire about choking episodes, recent trauma, and exercise or activities that could cause pain from muscle strain or overuse. • It is critical to distinguish a history of exercise (that could cause muscular chest wall pain) from exercise as a precipitating factor (which may be consistent with ischemic pain and mandates an urgent cardiac evaluation). • Associated syncope is very worrisome and also mandates a cardiac evaluation. History
  5. 5. • A medication history could provide clues to a potentially causative etiology (oral contraceptives) or the possibility of mucosal injury (e.g., tetracycline, NSAIDs); also investigate the possibility of substance abuse, especially cocaine and methamphetamine. • Evaluation of psychosocial factors in the child’s life is very important. • Ask about school attendance and performance, relationships with friends and family, and any current stresses or conflicts. • The family history should inquire about hypercholesterolemia, Marfan syndrome, and cardiomyopathy. • A family history of recurrent syncope or unexplained sudden death may suggest hypertrophic cardiomyopathy or long QT syndrome. • Heart disease in an adult family member may provoke anxiety- related chest pain in a younger person. History
  6. 6. • A complete thorough physical exam is necessary; focusing on the chest exam may miss findings pertinent to a noncardiac underlying cause of chest pain. Physical Examination
  7. 7. Etiology • Musculoskeletal chest wall pain • Trauma Fracture. • Skin: herpes zoster • breast disorders • Respiratory: Asthma, Pleurisy (pleuritis) • GIT: Gastroesophageal reflux disease (esophagitis) Peptic ulcer disease • Cardiac : Pericarditis & Myocarditis • psychological disorders
  8. 8. Musculoskeletal • Costochondritis is pain due to inflammation of the costochondral joints (where the bony rib meets the costal cartilage). • It is a common cause of chest pain in children and is usually unilateral, sharp, transient in nature, and can be reproduced by palpation on examination. • Tietze syndrome, a rare form of costochondritis, affects a single chostochondral, costosternal or sternoclavicular joint and causes notable swelling, tenderness, and warmth localized to the affected joint.
  9. 9. Musculoskeletal • Other skeletal causes of chest pain include traumatic injury, spondyloarthritis, and stress fractures. The latter should be considered in athletes with repetitive upper extremity motions, especially in the absence of a recognized acute traumatic event; a bone scan should be considered if suspicion is high and x-rays are negative. • Chest wall deformities (pectus carinatum, pectus excavatum) are rare causes of pediatric chest pain.
  10. 10. • Muscular chest wall pain is common in weight-lifters, but carrying heavy back packs, severe coughing, and sports involving rotation or twisting can also be causative. • Sharp pain in the intercostal muscles can occur with infection due to coxsackie and other enteroviruses. • This pain (historically called pleurodynia or Bornholm disease) is sudden in onset, paroxysmal, and accompanied by fever and other systemic signs of enteroviral infection (e.g., vomiting, headache, sore throat). • Sometimes the illness exhibits a biphasic pattern with a recurrence of the chest pain and fever several days after the initial presentation. Musculoskeletal
  11. 11. Breast Disorders • Early puberty may cause chest pain related to breast nodule development in males and females. • Other breast disorders including infections, cystic disorders, pregnancy, and menstrual swelling may cause chest pain in females.
  12. 12. Shingles (herpes zoster) • Pain related to shingles (herpes zoster) may precede the appearance of the rash. • Children affected by hypersensitivity pain syndromes may complain of pain with light touch to their chest wall, or even with wearing certain clothing; other somatic complaints are typically present as well.
  13. 13. Asthma • Chest pain is occasionally the initial presentation of asthma. • A history of nocturnal cough, atopy or a remote history of bronchospasm may support the diagnosis. • Bronchoconstriction is often reported by children as chest pain. • Prolonged cough (due to acute exacerbations or poor control of asthma) can lead to soreness of chest wall muscles. • Asthma also sometimes presents with a complaint of chest pain with running or exertion (with or without coughing). • Chest x-ray findings are often normal, but may reveal hyperinflation, atelectasis, or peribronchial thickening.
  14. 14. Psychogenic chest pain • It is difficult to clearly define the role of psychological disorders in cases of pediatric chest pain because of inconsistent use of valid psychological assessment tools and differences in research terminology in this area. • Stress, anxiety, mood disorders, somatoform disorders, depression, and psychotic disorders have all been associated with chest pain; the validity of these diagnoses is impacted by the use (or misuse or nonuse) of appropriate psychological assessments. • The psychological impact of organic causes of chest pain on patients is also poorly defined, even though it is likely very relevant to patients and families dealing with a serious medical diagnosis.
  15. 15. • Providers must be cognizant of the importance of using valid assessments to diagnose psychological disorders; psychogenic chest pain should never be a diagnosis of exclusion. • Hyperventilation typically presents with rapid breathing, dyspnea, anxiety, and sometimes with palpitations, chest pain, paresthesias, lightheadedness, and confusion. • Careful evaluation often reveals anxiety or underlying psychological concerns. Psychogenic chest pain
  16. 16. Precordial catch syndrome • Precordial catch syndrome (Texidor twinge) is classically described as a benign condition characterized by brief paroxysms of sharp, well- localized pains in the midsternal or precordial region. • Episodes are brief (30 seconds to 3 minutes), self- resolving, and exacerbated by deep breathing. • Expert opinions vary regarding whether this phenomenon is a distinct entity, or if it should be considered an idiopathic etiology of chest pain.
  17. 17. Pericarditis & Myocarditis • Infections are rare but serious causes of chest pain in children. • Chest pain is frequently a prominent symptom in pericarditis; it is usually exacerbated by lying down or with inspiration. • Physical examination findings include a friction rub, muffled heart sounds, tachycardia, neck vein distention, and pulsus paradoxus. • Myocarditis presents with a more subtle but progressive illness, including fever, chest pain, vomiting, and shortness of breath. Electrocardiograms are abnormal in each of these conditions, and cardiomegaly is evident on chest x- ray.
  18. 18. Pneumothoraces • Asthma, cystic fibrosis, and connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome, ankylosing spondylitis) are risk factors for pneumothoraces. • Pneumonias due to certain pathogens (e.g., Pneumocystis jirovecii in immunodeficient conditions or staphylococcal, anaerobic gram negative pathogens) also predispose to the development of pneumothoraces. • Healthy children may also develop spontaneous pneumothorax; cocaine use is a risk factor. • Forceful vomiting is a rare cause of esophageal rupture causing pneumomediastinum (Boerhaave syndrome). • Traumatic or iatrogenic causes should also be considered.
  19. 19. Pleurisy (pleuritis) • Movement and deep breathing often aggravate the pain associated with pleurisy (pleuritis) or pleural effusions. • Bacterial pneumonias are the most common cause of pleuritis in children; collagen vascular disorders can also be causative.
  20. 20. Pulmonary emboli • Risk factors for venous thrombosis (e.g., oral contraceptives, recent abortion or surgery [especially cardiac], the presence of a central venous line, immobilization, sepsis, hypercoagulable states, vascular malformations) should raise suspicion for pulmonary emboli. • Associated symptoms include dyspnea, cough, hypoxia, and occasionally, hemoptysis. • If emboli are suspected, appropriate labs and imaging (spiral CT or pulmonary angiography) should be performed.
  21. 21. Slipping rib syndrome • Slipping rib syndrome is characterized by pain along the lower rib margin of the upper abdomen, sometimes associated with a slipping sensation and a popping or clicking sound. • Although a clear consensus on the cause of the pain is lacking, a commonly presumed etiology is that trauma to the eighth, ninth, or tenth rib causes a sprain-like injury, which increases the mobility of the rib and allows impingement on an intercostal nerve. • Reproduction of the pain by hooking the fingers under the anterior costal margins and pulling the ribs forward is characteristic.
  22. 22. GERD (gastroesophageal reflux disease) • Symptoms of GERD (gastroesophageal reflux disease) vary by age; common symptoms in older children and adolescents are abdominal or substernal pain, vomiting or regurgitation, increased pain after meals or when recumbent, and relief with antacids. • A trial of empiric therapy is appropriate in children with typical symptoms, although a positive response is not confirmatory of GERD since spontaneous resolution of symptoms (due to any cause) can occur.
  23. 23. Peptic ulcer disease (PUD) • Peptic ulcer disease (PUD) frequently presents with a chronic intermittent history of dull or aching pain and often includes nighttime complaints. • The pain may be epigastric or poorly localized abdominal pain; it may or may not be relieved by antacids.
  24. 24. Eosinophilic esophagitis (EoE) • Eosinophilic esophagitis (EoE) is diagnosed by endoscopic biopsies showing localized eosinophilic infiltrates of the esophagus. • The condition is being increasingly recognized in all age groups; abdominal pain and vomiting are more common in younger children and dysphagia, chest pain, and food impaction are more likely in adolescents. • Other atopic diseases and food allergies are commonly associated.
  25. 25. Cardiac causes • Consultation with a cardiologist is recommended because of the potentially serious (ischemic) nature of chest pain caused by severe obstructive lesions; it is also considered a more cost-effective alternative to obtaining additional studies without consultation.
  26. 26. • Hypertrophic cardiomyopathy is a genetic disorder transmitted in an autosomal dominant pattern, although a large proportion of cases are considered de novo mutations. • Classic physical examination findings include a left ventricular lift and a harsh systolic ejection murmur that is increased with any maneuver that decreases venous return (Valsalva maneuver, rising from squatting to standing). • As the development of hypertrophy is gradual over years, examination findings in children may be limited to nonspecific murmurs; cardiac evaluation is indicated whenever there is a known family history.
  27. 27. • Unless suspected to be asthma, chest pain that is precipitated by exercise or running or is associated with syncope or palpitations warrants urgent cardiac consultation. • Myocardial ischemia is rare in children overall, although an increasing number of children are at risk due to advances in care and treatment of congenital and acquired (Kawasaki) heart disease. • Unlike adults with atherosclerotic heart disease, children do not experience classic angina-type pain (i.e., chest pressure or squeezing sensation with radiation to neck, jaws or arms); rather, the symptoms of myocardial ischemia in younger patients are nonspecific and include irritability, nausea, vomiting, abdominal pain, failure to thrive, shock, syncope, seizures, or sudden cardiac arrest.
  28. 28. • The presentation of congenital coronary artery abnormalities may be subtle or abrupt with few identifiable risk factors. • However, children with a history of heart surgery (e.g., repair of tetralogy of Fallot or transposition of the great arteries), congenital heart conditions, or a history of Kawasaki disease warrant a higher threshold of awareness for risk of ischemic chest pain.
  29. 29. • Coronary artery anomalies are rare but can be associated with severe ischemia. • The physical examination may be normal or may include tachypnea, tachycardia, pallor, diaphoresis, distant heart tones, a murmur consistent with mitral regurgitation, or a gallop rhythm suggesting myocardial dysfunction. • Echocardiogram and angiography are used in diagnosis.
  30. 30. THANKS FOR YOUR Attention
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Chest pain in children

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