Transcript Chest Pain - University of Michigan School of Nursing

Chest Pain
In Children
and
Adolescents
Caroline L. Derrick BSN, RN
University of Michigan
Most causes are
Benign
• Common Complaint
from Children in ER
• Known association
with myocardial
infarction (MI) and
sudden death in adults
• In children, Cardiac
causes are the least
likely in association
with presenting chest
pain.
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Studies
• Nurse Practitioner Study:
50 Children with CP
referred to Pediatric
Cardiologist- non-cardiac
cause.
• 3/1,000 children visiting
ER for CP, only 1% were
cardiac in nature
• LT outcomes in idiopathic
CP- 81% reported no CP
after 3 year follow up.
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Differential
Diagnosis
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Musculoskeletal
Respiratory
GI
Idiopathic
Psychogenic
Cardiac
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Musculoskeletal
Pain
• Muscle Strain: Chest wall
pain- usually associated with
strain of muscles and may
occur with excessive exercise
or trauma.
• Strain of the upper back or
pectoral muscles
• Direct trauma to the
chest- athletics, accidents,
physical abuse. Trauma may
include rib fractures, intercostal
muscle strain, pneumothorax or
hemothorax.
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Costochondritis
• 10-22% Childhood CP
• Local, sharp pain in the
mid-sternal area
• Reproducible pain with
palpation along
costochondral margins
• May last for several
months
• More common in girls
• Treatment: Reassurance,
NSAIDS, rest
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Slipping Rib
Syndrome
• Sprain disorder r/t trauma to 8th,
9th, 10th ribs
• Sensation of ribs “slipping”
• Pain with flexing the trunk,
turning over, deep breathing,
prolonged walking, coughing
• Positive “hooking maneuver”
• Treatment: reassurance,
injection of local anesthetic,
possible surgical removal of
affected cartilage.
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Respiratory
Causes
• Pneumonia and Asthma may
cause excessive coughing, may
continue to overuse chest wall
muscles.
• Pleural Effusions- pain
exaggerated by deep breathing
• Pneumothorax- Chest pain
• Tachypnea, retractions,
wheezing, fever, decreased
breath sounds.
• CXR, SpO2%, peak flow meter
levels
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Gastrointestinal
Pain
• 2-7% of all causes of CP in
adolescents
• Esophagitis/GERD- “burning”,
aggravated in a reclined
position.
• Pain with eating meals or spicy
foods
• Foreign body ingestiontoddlers; lodged in proximal
esophagus
• Caustic Ingestions- household
cleaners- damage to
esophagus
• *** Bulimia Nervosa- purgingesophagitis/ perforation.
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Idiopathic CP
• Most common cause of
childhood/adolescent CP
• No organic or psychogenic
cause after thorough history,
PE, labs
• Emotional stress/Anxiety,
especially in girls
• Hyperventilation Syndromehypercapnic alkalosis.
Associated with
lightheadedness, HA and
parasthesias
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Rare Causes of
CP
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Thoracic tumor
Sickle Cell Disease
Herpes Zoster
Ectopic Pregnancy
Precordial Catch- Texidor’s
Twinge- Syndrome associated
with CP. Described as brief
(less than 5 minutes), sharp,
shooting, left sided pain
• Pain subsides with shallow
breathing and straightened
position
• Thought to be produced by
pressure on intercoastal nerve
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Cardiac Causes of CPCongenital Anomalies
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Mitral Valve Prolapse(MVP)
Most prevalent cardiac lesion
associated with CP in
children/adolescence
Associated with thickening of mitral
valve leaflets- bulge into the
annulus.
Pain results from Left ventricular
endocardial ischemia as the valve
prolapses
30% of MVP patients report CP
Mid-systolic ejection “click”
Systolic ejection murmur id
regurgitation is present
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Cardiac causes of CPCongenital Anomalies
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Left ventricular outflow obstructiongroup of lesions that produce a
significant risk for ischemic
myocardial dysfunction.
Aortic Stenosis (AS) commonprogressive over time- associated
with bicuspid aortic valve
Causes a decrease in CO
CP with exertion
PE- systolic ejection click, systolic
murmur over aortic valve region
and palpable thrill at suprasternal
notch
Aortic Stenosis Murmurs become
louder when going from standing to
squatting.
EKG- hypertrophy patterns may be
present
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Cardiac causes of CPCongenital Anomalies
• Subaortic Stenosis/ IHSSobstructive lesions also
associated with CP with
exercise and exertion.
• Harsh systolic murmor
heard from squatting to
standing.
• IHSS inherited lesionautosomal dominant
pattern
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Cardiac causes of CPCongenital Anomalies
• Anomalous Origin of the
Left Coronary Artery- rare
• Limited coronary artery
blood flow, causing
ischemia
• Angina type pain, syncope
• PE- Pan systolic
continuous or mitral
regurgitant murmur may
be heard as well as a
gallop.
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Acquired
Conditions
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Pericarditis- infectious process
causing inflammation of the
pericardium
Sharp, shooting pain
Precordial in location
Often relieved by leaning forward
Cough fever, respiratory distress
may be present
PE- heart sounds may be distant,
muffled; a rub may be auscultated
Rub may disappear with
development of pericardial effusion
EKG: ST segment or T wave
change
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Acquired
Conditions
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Kawasaki Disease- a history of this
disease with coronary artery
involvement, presenting with CP
should be considered for
myocardial ischemia.
Immunoglobulin treatment- without
20-25% children have coronary
artery involvement at the time of
presentation.
If administered within 10 days,
incidence falls from 3-5%
Children with coronary artery
abnormalities almost always have
left ventricular hypertrophy
EKG: Abnormal ST segment or
inverted T waves are noted in
precordial leads.
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Acquired
Conditions
• Cardiomyopathy- general term
used to describe ventricular
dysfunction
• Many types- only some present
with CP
• Fatigue, decreased exercise
tolerance, palpitations
• Dilated Cardiomyopathy may
have CP with exertion and a
systolic murmur.
• Ask about a familial history of
sudden cardiac death when a
child has dilated
cardiomyopathy.
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Acquired
Conditions
• Myocarditis preceded by viral
illness
• Children may have a fever,
malaise, nonspecific CP,
respiratory distress.
• PE- may produce evidence of a
gallop
• Chest radiographcardiomegaly
• ECG- ST segment depression
and T wave abnormalities
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Arrhythmias
• SVT (Supraventricular
tachycardia)- may cause CP.
Most common childhood
arrhythmia
• Rapid heartbeat>200 bpm
• PE: diaphoresis, pallor,
hypotension, syncope
• Can convert to SR with vagal
Stimulation
• Frequent episodes of syncope,
treatment options include:
pharmacologic therapy
(Adenosine) or ablation
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Arrhythmias
• Ventricular Tachycardia (VT)rare but associated with CP
• Wide complex tachycardia
• Rate 120-140 bpm
• Medical Emergency- may
progress to Ventricular
fibrillation
• Causes: viral myocarditis,
surgically induced sequelae or
prolonged QT interval.
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Questions to Ask:
Past Medical History
• History of: asthma,
sickle cell disease,
rhematic fever, cystic
fibrosis?- CP may
indicate a
complication.
• History of congenital
or acquired heart
disease? Even if it
was fixed may
produce CP.
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Severity of CP
• Scale “0-10” or smiley
faces
• Worst pain ever?
• Interfere with daily
activities?
• What makes the pain
better? Worse?
• Any associated factors
related to the chest pain?
• Organic vs. Psychogenic
pain
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Onset, Frequency,
Duration
• When did the pain start?
• What were you doing when the
pain started?
• How often does the pain occur?
• When does the pain occur?
What activities are you doing?
• How long does the pain last, is
it continuous or does it come
and go (intermittent)?
• How long has this been going
on?
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Type and
Location
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How would you describe the pain?
Sharp, dull, burning, pressure, etc?
Sharp pain- costochondritis,
musculoskeletal, may be located
along costochondrial junction
Burning- espohagitis, indigestion,
may be located at midsternal area.
Where is the pain located, does the
pain radiate (travel) to any other
areas? (jaw, neck, shoulders,
abdomen, arm, etc.)
• Sharp pain that radiates to the
neck, back and shoulders may
be associated with
pneumomediastinum
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Associated
Symptoms
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Palpitations
Dizziness
Syncope with CP
*** These symptoms are
associated with cardiac
causes of CP and should
be taken seriously
• Recent Flu like symptoms,
prolonged fever with new
onset of CP- endo,
pericarditis, myocarditisimmediate work-up
required
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Precipitating
Factors
• Anxiety- explore
recent events- new
school?, etc.
• Tend to complain of
CP during the week
but not on weekends,
holiday breaks or
summer.
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Family Events
• Ill family member?
Divorce? Physical or
sexual abuse?
• Girls: BCP- rare
Pulmonary embolism
• Depression- stressors
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Family History
• Pivotal
• History of acquired or
congenital heart disease,
Marfan Syndrome or history of
arrhythmia
• Critical- history of sudden
cardiac death in a family
member
• Idiopathic hypertrophic
subaortic stenosis- autosomal
dominant disorder associated
with sudden cardiac death.
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Physical Exam
• Complete
• Signs of severe distress, pain,
anxiety
• Vital signs,BP and weight within
range for age?
• Assess respiratory function for
distress or abnormalities
• Ecchymosis, trauma, rash,
chest heave, abnormal shape
of chest, scoliosis or syndromic
appearance.
• Tall and thin with long fingers
and toes? (Marfan Syndrome)
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Physical Exam
• Palpate chest wall to attempt to
reproduce or locate source of
CP
• Include clavicals, entire chest
wall, breasts and zyphoid area
• Assess for palpable thrill or RV
heave- both consistent with
congenital and acquired heart
disease
• Subcutaneous emphysematrauma or spontaneous
pheumothorax?
• Palpate abdomen- tenderness
and assess for
hepatosplenomegaly
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Physical Exam
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Palpate extremities for warmth and
general perfusion
Assess pulses in all four
extremities for equality and
strength
Hooking maneuver
Auscultate the heart for murmurs,
gallops, rubs, dysrhythmias and
any other abnormal heart sounds
Auscultate in supine, sitting ,
standing and squatting positionshelps to hear murmurs of AS and
sub AS.
Lie patient on left side- assess for
murmur of mitral regurgitation or
mitral valve click
Auscultate all lung fields assess for
wheezes, rales, or asymmetry of
breath sounds
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Further
Evaluation
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Labs usually not needed
In most cases, H& P will clarify
cause
Consider peak flow meter if asthma
may be the cause
Order CXR if signs of pleural
effusion, pneumothorax,
pneumonia, chest trauma, or bone
fracture
Consider pregnancy test
12 lead ECG
Holter Monitors, journal/diary
Journal/diary of events surrounding
CP
Exercise Stress Testing- cardiac
rhythm during exercise
Referral if cardiac in origin
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Good Prognosis
• CP in children/adolescents
common and rarely cardiac
related
• Thorough H & P essential to
rule out rare and life
threatening causes of CP
• Most causes of CP are benign
and cause no further sequelae.
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