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

Table of Contents

 

About This Issue

Although chest pain is a relatively common presenting complaint in pediatric patients, no standardized approach to the emergency department evaluation of chest pain in children exists. This issue reviews the available literature to provide evidence-based recommendations for a more standardized approach to the evaluation and management of pediatric patients with chest pain. You will learn:

Common causes of cardiac chest pain and non-cardiac chest pain (including musculoskeletal, respiratory, immunologic and/or rheumatologic, gastrointestinal, and psychogenic etiologies)

Conditions in the differential diagnosis of chest pain caused by cardiac pathologies that have the highest risk for deteriorations or subsequent sudden death

Red-flag findings on the history and physical examination that that could indicate a cardiac etiology

Electrocardiogram findings that indicate a cardiogenic cause of chest pain

Treatment recommendations for patients with cardiac conditions, musculoskeletal conditions, pulmonary conditions, and gastrointestinal conditions

When admission or prolonged observation is required

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Epidemiology
   1. Prevalence of Asthma and Healthcare Costs
   2. Social Determinants and Risk Factors
7. Etiology and Pathophysiology
8. Differential Diagnosis
   1. Congestive Heart Failure
   2. Chronic Obstructive Pulmonary Disease
   3. Pneumonia/COVID-19
   4. Pulmonary Embolism
   5. Other Conditions in the Differential for Asthma
9. Prehospital Care
10. Emergency Department Evaluation
    1. History
    2. Physical Examination
       1. Classifications of Asthma Exacerbation
          • Mild Exacerbation
          • Moderate Exacerbation
          • Severe Exacerbation
11. Diagnostic Studies
    1. Laboratory Evaluation
    2. Point-of-Care Ultrasound
    3. Blood Gas
    4. Peak Expiratory Flow
    5. End-Tidal CO2 Monitoring
    6. Chest Radiographs
12. Treatment
    1. Oxygen
    2. Pharmacologic Agents
       1. Beta Agonists
          • Metered-Dose Inhalers Versus Nebulizers
          • Intermittent Versus Continuous Nebulizer Treatments
       2. Anticholinergics
       3. Corticosteroids
       4. Magnesium Sulfate
       5. Epinephrine
       6. Terbutaline
       7. Ketamine
    3. Noninvasive Positive Pressure Ventilation
    4. Intubation and Mechanical Ventilation
13. Special Populations
    1. Pediatric Patients
    2. Pregnant Patients
    3. Asthma Patients With COVID-19
14. Controversies and Cutting Edge
    1. Biologics
    2. Fractional Exhaled Nitric Oxide
    3. Heliox
    4. High-Flow Nasal Cannula
    5. Delayed Sequence Intubation
    6. Extracorporeal Membrane Oxygenation
15. Disposition
16. Time- and Cost-Effective Strategies
17. Risk Management Pitfalls for Asthma Exacerbations in the Emergency Department
18. Summary
19. Case Conclusions
20. Acknowledgment
21. Clinical Pathway for Management of Asthma Exacerbations in the Emergency Department
22. Tables and Figures
23. References

Abstract

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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Clinical Pathway for Management of Chest Pain in Pediatric Patients

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Drossner DM, Hirsh DA, Sturm JJ, et al. Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain. Am J Emerg Med. 2011;29(6):632-638. (Retrospective study; 4288 patients) DOI: 10.1016/j.ajem.2010.01.011

2. * Mohan S, Nandi D, Stephens P, et al. Implementation of a clinical pathway for chest pain in a pediatric emergency department. Pediatr Emerg Care. 2018;34(11):778-782. (Retrospective study; 1687 patients) DOI: 10.1097/pec.0000000000000861

4. * Selbst SM, Ruddy RM, Clark BJ, et al. Pediatric chest pain: a prospective study. Pediatrics. 1988;82(3):319-323. (Prospective study; 407 patients) DOI: 10.1542/peds.82.3.319

44. * Babbitt CJ, Babbitt MJ, Byrne F, et al. Pediatric myopericarditis presenting to the emergency department as chest pain: a comparative study with myocarditis. Pediatr Emerg Care. February 12, 2021. (Retrospective study; 36 patients) DOI: 10.1097/pec.0000000000002376

50. * Dalal A, Czosek RJ, Kovach J, et al. Clinical presentation of pediatric patients at risk for sudden cardiac arrest. J Pediatr. 2016;177:191-196. (Retrospective chart review; 450 patients) DOI: 10.1016/j.jpeds.2016.06.088

110. *Brancato F, De Rosa G, Gambacorta A, et al. Role of troponin determination to diagnose chest pain in the pediatric emergency department. Pediatr Emerg Care. 2021;37(12):e1589-e1592. (Retrospective observational study; 99 patients) DOI: 10.1097/pec.0000000000002123

113. *Neff J, Anderson M, Stephenson T, et al. REDUCE-PCP study: radiographs in the emergency department utilization criteria evaluation-pediatric chest pain. Pediatr Emerg Care. 2012;28(5):451-454. (Retrospective chart review study; 400 patients) DOI: 10.1097/PEC.0b013e31825355b5

121. *Kanis J, Pike J, Hall CL, et al. Clinical characteristics of children evaluated for suspected pulmonary embolism with D-dimer testing. Arch Dis Child. 2018;103(9):835-840. (Retrospective study; 526 patients) DOI: 10.1136/archdischild-2017-313317

123. *Kanis J, Hall CL, Pike J, et al. Diagnostic accuracy of the D-dimer in children. Arch Dis Child. 2018;103(9):832-834. (Retrospective study; 2554 patients) DOI: 10.1136/archdischild-2017-313315

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Keywords: chest pain, cardiac chest pain, noncardiac chest pain, myocarditis, pericarditis, myopericarditis, perimyocarditis, hypertrophic cardiomyopathy, anomalous aortic origin of a coronary artery, AAOCA, aortic dissection, arrhythmia, electrocardiogram, biomarkers, chest radiography, chest x-ray