Chest Pain in Children and Adolescents What an EMS Needs to Know. Frank C. Smith, M.D. Pediatric Cardiology Associates

Transcription

1 Chest Pain in Children and Adolescents What an EMS Needs to Know Frank C. Smith, M.D. Pediatric Cardiology Associates

2 Chest Pain in Children and Adolescents Common in children (10-15%) Non-cardiac causes are most common Cardiac causes are rare Usually excluded by history and physical exam Boston Children s study 5/3700 pts had cardiac cause, and those causes were relatively benign History is most important diagnostic tool Other tests sometimes needed to exclude heart disease ECG chest X ray cardiology consult/echo

3 Chest Pain in Children and Adolescents General Causes Idiopathic Musculoskeletal strain, trauma, costochondritis Pulmonary cough, asthma, pneumothorax Gastroesophageal reflux Psychogenic Cardiac

4 Chest Pain in Children and Adolescents Cardiac Causes Aortic obstruction and/or coronary insufficiency usually exertional Hypertrophic cardiomyopathy with obstruction Aortic stenosis Coronary artery anomaly/aberrancy Thrombosed coronary artery aneurysm post Kawasaki Syndrome Coronary atherosclerosis (very rare)

5 Chest Pain in Children and Adolescents Cardiac Causes Other Causes Arrhythmia (PVC s, SVT, VT) Pericarditis or myocarditis?mitral valve prolapse Dissecting aortic aneurysm (Marfan Syndrome) Drugs

6 Two Rare Cardiac Causes of Chest Pain Hypertrophic Cardiomyopathy (IHSS) Coronary Aneurysms Kawasaki Syndrome

7 Take a Thorough History If necessary, give options for answers and don t lead the witness! Symptom Cardiac Non-Cardiac Location midsternal anywhere Onset recently months or year ago Character pressure/crush sharp/burn Activity worsens it +/- change Duration until resting secs./mins. Radiation shoulder/arm none Breathing No change + or Ext. pressure No change + or S.O.B/dizzy? Yes No Dizziness? Maybe No With food? No Maybe

8 Chest Pain in Children and Adolescents Additional History Recent increase in physical exertion Start of sports season/practice Repetitive exercise Batting, driving golf ball, chin ups, weight lifting, pitching baseball repetitively Use of heavy back pack Recent heavy lifting Responds to ibuprofen/tylenol (musculoskeletal)

9 Chest Pain Evaluation Past Medical History Long standing diabetes (coronary artery disease) Marfan Syndrome (aortic aneurysm/dissection) Kawasaki Disease (coronary aneurysms) Sickle Cell Anemia (chest syndrome) SLE (rare) Drug abuse Previous pulmonary disease/asthma

10 Chest Pain Evaluation Family and Social History Marfan syndrome or aneurysms (dissection) History of sudden death (ischemia from hypertrophic CM, or VT from long QT syndrome) History of smoking, alcohol or drug intake

11 Chest Pain Physical Findings Cardiac exam is usually normal, but check for Murmur that increases with standing/valsalva Hypertrophic cardiomyopathy with obstruction Pericardial friction rub Pericarditis Decreased air entry Pneumonia, pnuemothorax, atelectasis Look for rib/chest trauma or asymmetry

12 Auscultation of the Heart Change with Maneuvers Examine child first seated and supine, and standing if possible: Systolic ejection murmur Louder supine: benign or functional murmur Louder standing: Hypertrophic cardiomyopathy with obstruc tion (IHSS) Mid-late systolic murmur with mid-systolic click Louder standing, softer squatting: mitral valve prolapse

13 Murmur Intensifies with Standing Think Hypertrophic Cardiomyopathy

14 Chest Pain Additional Tests Chest X ray pneumonia pleural effusion pneumomediastinum/thorax fracture cardiomegaly ECG ST elevation with pericarditis, ST elevation/depression with HCM SVT (or WPW) VT (or long QTc interval) Troponin level ECHO (depends upon history, physical exam, FH) Stress test/stress echo in rare cases

15 Wolff-Parkinson-White pattern

16 Congenital Long QT Syndrome

17 Hypertrophic Cardiomyopathy-- Pain is exertional, midline, pressure-like May be associated with syncope Systolic ejection murmur at mid/lower LSB Murmur louder with standing or Valsalva* Diastolic filling sound or gallop may be heard Positive Family History IHSS

18 Hypertrophic Cariomyopathy

19 Chest Pain Acute Pericarditis Usually acute (onset within days) Pain varies with body position Associated with fever, constitutional symptoms Pericardial friction rub Usually viral (Coxsackie)

20 Acute Pericarditis