Chest Pain in Children: It's Not All Heart • None

Home , Acute chest syndrome, Chest pain in children

6/18/2019

Disclosures Chest Pain in Children: It's Not All Heart • none

• Cathy S. Woodward, DNP, RN, PNP-AC • Professor of Pediatrics • UT Health -San Antonio

•List the most common causes of benign chest pain in children. •Discuss the differential for children presenting with acute chest pain. •Describe the must-not-miss assessments in children with serious chest pain.

Chest Pain Incidence of CP complaints •3700 kids evaluated for CP only 1% related to cardiac cause. •Musculoskeletal •Pulmonary •Gastrointestinal •Anxiety •Unknown cause

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Musculoskeletal CP

•Brief sharp chest pain •Worse with deep breathing and movement •History of trauma, fall, new exercise, cough

Musculoskeletal Causes of CP Slipping Rib Syndrome

•31% of children who see cardiologists •Described in 1919 •Connective, bony and muscular tissue •Hypermobility of ant ends of ribs 8-10 •Precordial catch – short duration, unclear •Precipitating cause – cough, exercise, etiology trauma •Costochondritis •Pain acute and is reproducible •Trauma •Hooking maneuver • Slipping rib syndrome

Pulmonary Causes of CP Pneumothorax •Chest Pain with •Asthma SOB •Pneumonia/Pleuritis •Trauma or •Chronic cough spontaneous •Pneumothorax •No breath •Acute Chest Syndrome sounds on affected side

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Acute Chest Syndrome Gastrointestinal Causes of CP

•Major cause of morbidity and mortality for •Esophageal reflux – burning pain, center of children with Sickle Cell Disease – vaso chest, pain increased or decreased by certain occlusive crisis foods and body position •Pulmonary infiltrates, CP and fever, hypoxia •Cholecystitis - rare •Caused by embolism, bacterial or viral infections, asthma, lung infarct.

Psychological Causes of CP Non-Cardiac Chest Pain

•Preceding Stressful event •Push on chest - if pain is reproducible then not cardiac •Hyperventilation •Pain increases with breathing or •Depression movement •Brief CP •Normal Vital signs

Serious Chest Pain Cardiac Causes of CP •Severe, unrelenting pain •Fast heart rate •Congenital heart disease •Diaphoresis •Acquired heart disease •Fever •Dysrhythmias •SOB •Tumors •Recent illness •Cardiomyopathy

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Congenital Heart Disease Obstructive Lesions • •Left ventricular outflow obstruction – Decreased pulses in Aortic stenosis – CP with dizziness or Left arm and lower fatigue legs. • •Obstructive Lesions – Coarctation of Cool extremities Aorta •Hypertension •Cyanotic Heart Disease – worsening •Often dx during hypoxia or dysrhythmias pre-sport physicals •ALCAPA

Anomolous Left Coronary Aorta to Pulmonary Acquired Heart Disease

•Disease of the heart that develops after birth. •Affects heart muscle, heart valves or coronary arteries •Rheumatic Heart Disease – developing countries •Kawasaki Disease – developed countries •Myocarditis/Endocarditis •Cardiomyopathy

Acquired Heart Disease Prevention

• Rheumatic heart fever/disease •Untreated strep throat is the cause! • Rare in US •Most sore throats are caused by • Immigrant population viruses NOT Strep. • Post strept pneumococcal pharyngitis •Younger than 15 years • Autoimmune response to infection •Fever • Untreated infection •Tonsillar swelling or exudate • Untreated fever leads to disease • • Valvular disease Tender anterior cervical nodes •No cough

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Diagnosis of Rheumatic Fever Myocarditis/Endocarditis

• Jones Criteria – Major Criteria • Carditis •Serious, insidious viral or bacterial infections • Arthritis of the heart muscle and/or valves of heart • Presence of TWO MAJOR Subcutaneous Nodules or ONE MAJOR and TWO •Presenting Symptoms • Chorea MINOR is enough to • Rash – erythma marginatum clinically diagnose •Flu like – fatigue, malaise, fever rheumatic activity • Minor Criteria •Chest pain, palpitations • Fever •Endocarditis - Splinter hemorrhages, • Leukocytosis – increase WBC Janeway nodules and Osler’s nodules • Elevated ESR or CRP • Recent Streptcoccal infection

Kawasaki Disease Myocarditis • Leading cause of acquired heart disease in developed countries • Acute febrile illness • Vasculitis • Fever • Rash – erythema palms/soles, edema hands • Bilateral conjunctival redness – no exudate • Cracked lips, strawberry tongue • Cervical lymphadenopathy

Kawasaki Disease Cardiac Tumor

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Cardiomyopathy Dysrhythmias •Dilated - muscle fibers weak and •Irritable focus – children with hx of heart unable to contract disease •Hypertrophic – thickened and stiff •Fever ventricles can’t fill or contract •Stimulants •Restrictive – normal contraction, ineffective relaxation •Caffeine •Cocaine

Dysrhythmias Case Study

• Rapid Tachycardias •8 yr old with hx of CHD •Walking in hall at school and had sudden onset of CP and SOB •Sternal Scar

8 yr old with CP Assessment of Child with CP

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History History •Is pain new •Fatigue •How often does it occur •SOB •Where is pain •Pain worse with breathing? •Quality – sharp, dull, squeezing •Worse in different position? •Exercise make it worse? •Radiation of pain •Anyone else in family with chest pain? •What makes it better or worse •Recent stresses in your life •Associated symptoms •Medications? •Fainting? Dizziness?

Cardiac Questions Physical Assessment Have you ever passed out or nearly passed out during or after exercise? • Chest wall – PMI and abnormalities Have you ever had discomfort, pain, or pressure in your Apical impulse chest during exercise? < 7 yrs 4ICS just left of midclavicular line Does your heart race or skip beats during exercise? > 7 yrs 5ICS midclavicular line PMI laterally or downward – vent hypertrophy Does anyone in your family have heart problems or Marfan’s? PMI – RV dominance LLSB or xiphoid – Has a doctor ever ordered a test for your heart (e.g., Heaves – impulse diffuse and slow rising - vol overload electrocardiography, echocardiography)? Tap – localized and sharp – pressure overload Has anyone in your family died for no apparent reason? Precordial bulge – chronic cardiac enlargement Has anyone in your family died of heart problems or of unexplained sudden death before age 50?

Physical Assessment - Murmurs Physical Assessment

• Pulses and BP • Rate •If murmur becomes Softer with • Presence of pulse in all extremities Squatting • Weak or non-existent pulses in legs with strong arm pulses suggest COA – take blood •OR Louder or Longer with standing or pressures • Bounding pulses – run off lesions during valsalva • Pulsus paradoxus – greater than 10 mmHg •Think hypertrophic cardiomyopathy or difference during inspiration – pericardial effusion, cardiac tampanode, severe resp mitral valve prolapse distress. • FEVER

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Case Study 15 yr old with CP •15 year old, male, c/o chest pain “10” •Denies SOB, N/V •Hx of SVT •Cough and nasal congestion last three days •No fever •Meds: Digoxin, mucinex for allergies

Treatment with Adenosine Case Study

•15 year old female •C/o fatigue and chest pain x 3 days •Hx – viral type respiratory illness two weeks ago •HR 115 BP 90/50 RR 14 T 98.8

Case Study

•16 year old •Fever for three days and CP starting this am

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What to do while waiting for Ambulance Chest Pain in Children

•If ill appearing, abnormal vital signs or change in LOC – apply oxygen •Most often not emergent or serious •Keep NPO •Consider more serious if CP associated with •AED in the room •Fever •If hx of SVT – vagal maneuvers •SOB •Fast heart rate •Diaphoresis •Recent Illness

Questions? Chest Pain in Children: It's Not All Heart

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