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Pediatric Chest Pain: Using Evidence to Reduce Diagnostic Testing in the Emergency Department -

Pediatric Chest Pain: Using Evidence to Reduce Diagnostic Testing in the Emergency Department
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Publication Date: February 2022 (Volume 19, Number 2)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 02/01/2025.


Jay D. Fisher, MD, FAAP, FACEP
Associate Professor of Emergency Medicine; Program Director, Pediatric Emergency Medicine Fellowship, Kirk Kerkorian School of Medicine at UNLV; Medical Director, Pediatric Emergency Services, UMC Children's Hospital, Las Vegas, NV
Beth Warren, DO
Pediatric Emergency Medicine Fellow, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV

Peer Reviewers

Nicole Gerber, MD
Assistant Professor of Clinical Emergency Medicine and Clinical Pediatrics, New York-Presbyterian/Weill Cornell Medicine, New York, NY
Catherine E. Perron, MD
Assistant Professor of Pediatrics, Boston Children’s Hospital/Harvard University Medical School, Boston, MA


Pediatric chest pain is a relatively common presenting complaint, but identifying serious pathologies without overtesting patients with less-serious pathologies can be a challenge for emergency clinicians. This issue reviews the available literature to provide evidence-based recommendations to support a more standardized approach to the evaluation and management of pediatric patients with chest pain. This issue will help the emergency clinician identify red flags associated with cardiac causes of pediatric chest pain, recognize life-threatening causes of cardiac and non–cardiac chest pain, clinically diagnose the most common causes of non–cardiac chest pain, and appropriately utilize diagnostic tests in the evaluation of chest pain patients.

Case Presentations

A 15-year-old boy presents with severe left-sided substernal chest pain that began while exercising 2 hours prior...
  • The boy says that the pain does not radiate to his arms, neck, or back. He tells you he had a similar episode of chest pain the evening prior, which resolved spontaneously after 1 hour. The patient had been ill with a mild URI and diarrhea 3 weeks prior, which resolved in a few days without requiring medical attention. He had also been doing many pushups over the last few months with some increase in intensity recently.
  • On physical examination, the patient appears uncomfortable, with slight diaphoresis. His vital signs are: temperature, 36.3°C; heart rate, 58 beats/min; respiratory rate, 24 breaths/min; blood pressure, 143/65 mm Hg; and oxygen saturation, 100% on room air. His chest examination is notable for the absence of chest tenderness or neck crepitus. Heart sounds are normal and without murmurs, rubs, or gallops. His chest pain does not worsen when supine. Breath sounds are clear and without respiratory distress. The abdominal examination does not show liver engorgement. Strong pulses are felt in all 4 extremities, and there is no lower-extremity edema. The neurologic examination is without deficit.
  • Are there red-flag signs or symptoms that identify this patient as being at high risk for cardiac chest pain? What diagnostic workup is indicated for this patient?
A 10-year-old girl presents with substernal chest pain that started upon awakening for school...
  • The pain is described as severe and causes the child to breathe heavily. She also complains of “tingling” in her fingers and lips. The child had 1 prior episode of this a month ago that resolved after the child vomited forcefully. There has been no recent trauma, change in exercise pattern, fever, vomiting, or diarrhea. The pain is described as substernal pressure that radiates to the back. There is no radiation to the arms or neck. The patient says she feels better when sitting upright. She has been eating well.
  • Her vital signs are: temperature, 37.0°C; heart rate, 115 beats/min; respiratory rate, 22 breaths/min; and blood pressure, 118/78 mm Hg. The eyes and pharynx are without erythema. The chest examination is notable for clear breath sounds, no retractions, and no prolongation of the expiratory phase. There is mild chest tenderness over the left sternal border at the third and fourth rib spaces. The cardiac examination reveals normal heart tones and no murmurs, rubs, or gallops. The abdominal examination reveals tenderness in the epigastric and subxiphoid region but no peritoneal irritation or organomegaly. The girl’s extremities are normal, with good pulses. The neurologic examination is nonfocal, and her tingling has resolved. The girl rates her chest pain as 8 out of 10. The pain is worse when supine.
  • You consider asthma and pericarditis, as well as musculoskeletal and esophageal etiologies. Are there red-flag signs or symptoms that identify this patient as being at high risk for cardiac chest pain? What therapeutic interventions in the ED should you consider?


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