Chest Pain - Clinical Pathway: Emergency

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2 Gals Decrease: Chest X-ray Lab testing Bedside cardilgy cnsultatin ECG Decrease ED LOS Imprve parental satisfactin Metrics General ED Length f stay Testing Lab testing Chest X-ray ECG Vlume/Cst Use f Order Set

3 Outpatient Treatment Musculskeletal NSAIDS with adequate PO Fllw-up with PMD as needed Respiratry Treat asthma as indicated Treat pneumnia as indicated Fllw-up with PMD 7 days GI Ranitidine Fllw-up with PMD 7-10 days Psychlgical Decrease stimulants, caffeine Cmplete SW Cnsult t evaluate risk BHS when fr adlescents > 13 Meditatin, relaxatin techniques Fllw-up with utpatient MH as needed Fllw-up with PMD 7-10 days Any Psitive Risk Factrs fr Cardivascular Etilgy Exercise Restrictin: n gym, n sprts, kay t walk Click cardilgy fllw-up bx in Chest pain Discharge Smart Set: Within 1 week if psitive histry r physical exam Within 2 weeks if psitive past medical histry r family histry Fllw-up with PMD 7 days

4 Chief Cmplaint f Chest Pain Ppulatin Use this pathway t guide the evaluatin f the chief cmplaint f chest pain in healthy patients withut knwn cardiac disease. Exclusins: Knwn cardiac histry, cardiac surgery Sickle Cell Kawasaki Asthma Backgrund Infrmatin Chest pain is a cmmn chief cmplaint in pediatric utpatient and emergency department visits (0.6-5%) and is the 2nd mst cmmn reasn fr referral t a pediatric cardilgist. Parents and patients are cncerned abut the pssibility f heart disease which culd be very serius and/r life-threatening. Hwever, cardiac etilgies are exceedingly rare in healthy children and adlescents, < 1% f thse seen in the general utpatient setting r emergency department. In fact, f thse referred t a Pediatric Cardilgist, a cardiac etilgy will be fund n nly 2% f patients. Sme ther interesting facts: Average age f presentatin is 13 years with similar frequency in males/females Mst cmmn etilgy is idipathic (12-85%) r Musculskeletal (15-31%) Patients < 12 years: Cardirespiratry cause, slightly higher incidence f disease Patients > 12 years: Higher incidence f psychgenic cause 80% reslve spntaneusly A thrugh histry and physical examinatin will elucidate the etilgy r generate a shrt, specific differential diagnsis. Thus rutine labratry and radigraphic testing are nt rutinely indicated.

5 Histry and Physical Examinatin A thrugh histry and physical examinatin will elucidate the etilgy r generate a shrt, specific differential diagnsis. Thus rutine labratry and radigraphic testing are nt rutinely indicated. Assess VS and general appearance t determine if immediate treatment is needed. D nt immediately assume that the etilgy is cardiac. Evaluate the degree f pain and the impact that it has n the patient's life. Determine if the pain is part f an underlying chrnic cnditin. Cnsider further testing if histry r physical exam is cncerning. Avid expensive and invasive testing when pain is chrnic and histry and physical examinatin is benign. Histry Physical Exam Pain Onset, frequency, duratin Quality, severity Lcatin Radiatin, psitinal VS Fever HR, RR, BP Pulse ximetry Peripheral pulse, perfusin Trigger Exertinal General Appearance, acute distress, anxiety, chrnic appearance Assciated Symptms Dizziness, near syncpe r syncpe Dyspnea Palpitatins Fever, cugh Histry fr freign bdy Rash, arthralgia, arthritis Assciated with fds Alleviating factrs Freign bdy/caustic ingestin Chest Cr Murmur, S2 Gallp Frictin Rub Lung Wheeze Rales Fcal musculskeletal tenderness Crepitatins Asymmetry f chest Scial Anxiety, depressin, substance abuse Abdmen HSM, epigastric tenderness Medicatins Recent medicatins Other Rash, arthritis Evaluate fr evidence f trauma Thrmbphlebitis

6 Risk Factrs fr Cardivascular Etilgy Histry Physical Exam Past Medical Histry Family Histry Exertinal Acute nset, awakens frm sleep Substernal crushing pressure Radiatin t shulder, arm, neck, jaw Syncpe, dizziness Palpitatins Dyspnea Orthpnea Pulmnary emblus risk factrs Cyansis Tachypnea, shrtness f breath, WOB Abnrmal breath sunds Bradycardia, tachycardia, dysrhythmia HTN, hyptensin New murmur, significant murmur Gallp, frictin rub Abnrmal 2nd heart sund Distant heart sunds Rheumatlgic disease, SLE Neplasm Thrmbphilia Cnnective tissue disrder Marfan Behaviral health issue Anemia Diabetes Other chrnic medical prblems Sudden death in yuth Unexplained death Severe familial hyperlipidemia Cardimypathy Pulmnary hypertensin Deafness at birth Drug use Age < 12 years Decreased femral / peripheral pulses Peripheral edema

7 Outpatient Treatment Musculskeletal NSAIDS with adequate PO Fllw-up with PMD as needed Respiratry Treat asthma as indicated Treat pneumnia as indicated Fllw-up with PMD 7 days GI Ranitidine Fllw-up with PMD 7-10 days Psychlgical Decrease stimulants, caffeine Cmplete SW Cnsult t evaluate risk BHS when fr adlescents > 13 Meditatin, relaxatin techniques Fllw-up with utpatient MH as needed Fllw-up with PMD 7-10 days Any Psitive Risk Factrs fr Cardivascular Etilgy Exercise Restrictin: n gym, n sprts, kay t walk Click cardilgy fllw-up bx in Chest pain Discharge Smart Set: Within 1 week if psitive histry r physical exam Within 2 weeks if psitive past medical histry r family histry Fllw-up with PMD 7 days

8 Differential Diagnsis f Chest Pain in Children Cardiac Related Causes Crnary Artery Disease (ischemia, infarctin) Anmalus crnary artery Kawasaki disease Diabetes mellitus (lng-standing) Arrhythmia SVT VT Structural Abnrmalities Hypertrphic cardimypathy Severe pulmnic stensis Artic valve stensis Infectin Mycarditis Pericarditis Artic Dissectin (thracic) Histry Musculskeletal Disrders Chest wall strain Direct trauma, cntusin, rib fracture Cstchndritis Respiratry Disrders Severe cugh Asthma Pneumnia Pneumthrax, pneummediastinum Psychlgical Disrders Stress-related pain GI Disrders Reflux esphagitis Esphageal freign bdy, caustic ingestin Pill induced esphagitis Miscellaneus PE SCD with vascclusive crisis Abdminal artic aneurysm (Marfan) Pleural effusin (inflammatry disease) Zster

9 Pleurdynia (cxsackie virus) Breast tenderness (physilgic, pregnancy) Tietze syndrme Texidr's Twinge / Precrdial Catch syndrme Chest mass Idipathic Frm Selbst SM. Apprach t the Child with Chest Pain. Pediatr Clin Nrth Am Dec;57(6):

10 Characteristics f Pain and Etilgy Pericarditis Pain Sharp, stabbing sternal pain and L shulder pain Imprved by leaning frward +/- Cugh Frictin rub, muffled heart tnes Pulsus paradxus, distended neck veins with severe disease ECG +/- Cardimegaly n chest X-ray Mycarditis Pain Dull, substernal Fever, tachycardia, respiratry distress, fatigue Impending / existing shck Acutely ill-appearing Gallp, Mitral regurgitatin murmur ECG Lw vltage precrdial leads, ectpy Arrhythmia Acute nset and ffset f pain, palpitatins Mycardial Infarctin Pain Crushing, radiatin t neck, jaw Assciated diaphresis, dyspnea, nausea Substance expsure, abuse

11 ECG Tips Ptentially Cncerning ECG Findings in Patients with Chest Pain 1. Ischemia, Mycarditis r Pericarditis: Pathlgic ST Segment changes in 2 r mre cntiguus leads: Mre than 2mm abve baseline Abnrmal T wave mrphlgy and axis fr age Pathlgic Q waves (mre than 5mm deep and >40ms wide) in 2 r mre cntiguus leads 2, 3 Lw Vltage QRS amplitude (5mm r less in all six limb leads) 2. Right r Left Ventricular Hypertrphy: Right Ventricular Hypertrphy: Upright T wave between 4 days and Puberty in V1 Tall R V1 (>20-29 mm) and Deep S V6 (5-20mm) qr pattern in V1 Right axis deviatin fr age Left Ventricular Hypertrphy: Tall R V6 (>25 mm) r Tall R V5 (>35mm) and deep S V1(>25mm) Q in V6 > 4mm Left axis deviatin fr age 3. Prlnged QTc (calculated per Bazett's Frmula) greater than r equal t 450 msec 1, 4. Nte: Prlnged QTc in f itself rarely is an etilgy fr chest pain, these patients mre ften present with syncpe 4. Abnrmal Rhythm frm patient's baseline* Including abnrmal P wave axis (utside f 0-90 degrees) in setting f tachycardia Wide QRS fr age including a new bundle branch blck* 5. Frequent PVCs n a 12 lead ECG r multifrm PVCs *Assuming there is a prir ECG available References Eslick GD. Epidemilgy and risk factrs f pediatric chest pain: a systematic review. Pediatric Clinics f Nrth America. 2010, 57(6): Friedman KG, Kane DA, Rathd RH, et la. Management f pediatric chest pain using a standardized assessment and management plan. Pediatrics. 2011, 28(2): Saleeb SF, Li WY, Warren SZ, et la. Effectiveness f screening fr life-threatening chest pain in children. Pediatrics. 2011, 128(5):e Verghese GR, Friedman KG, Rathd RH, et la. Resurce Utilizatin Reductin fr Evaluatin f Chest Pain in Pediatrics Using a Nvel Standardized Clinical Assessment and Management Plan (SCAMP). J Am Heart Assc. 2012, 1(2).

12 Further Diagnstic Testing Labratry testing is rarely required in patients with chest pain. Please discuss indicatins fr labs with Cardilgy. Histry Physical Exam ECG Exertinal Acute nset, awakens frm sleep Substernal crushing pressure Radiatin t shulder, arm, neck, jaw Syncpe, dizziness Palpitatins Dyspnea, Orthpnea Risk Factrs fr PE Suspect drug expsure/abuse Cnsider with fever Ill appearance Significant VS abnrmality Abnrmal cardiac exam Cnsider with fever Chest X-ray, 2 view Fever Respiratry distress Trauma Awakens patient frm sleep Acute nset Histry f Kawasaki disease, CTD Suspect freign bdy Fever Ill appearance Significant VS abnrmality Abnrmal lung exam Abnrmal cardiac exam Crepitatins CBC, ESR, CRP Cncern fr my/pericarditis CK MB Studies Trpnin Cncern fr ischemia, my/pericarditis BMP Arrhythmia with abnrmal ECG Drug Screen Suspected drug use D-Dimer Cncern fr PE

13 BNP Cncern fr cngestive heart failure

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