Pediatric emergency medicine trisk 1064 1064
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CHAPTER 55 ■ PAIN: CHEST
ROBYN L. BYER
INTRODUCTION
The complaint of chest pain rarely represents a life-threatening emergency in
children, in contrast to the same complaint in adults. Although heart disease is an
uncommon source of chest pain in children, the fear of a cardiac origin for the
pain may evoke anxiety in the child or in the parents. There are a wide variety of
etiologies for chest pain including diseases of the respiratory, cardiac,
gastrointestinal (GI), neurologic, psychiatric, and musculoskeletal systems;
however, it is most commonly due to idiopathic noncardiac origins. Chest pain
accounts for approximately 0.6% of all pediatric emergency department (ED)
visits and affects boys and girls equally. Clinicians need to take a careful
approach to the patient even in the pediatric setting. This chapter first briefly
reviews the pathophysiology of chest pain, then outlines the differential diagnosis
in children, and finally presents the evaluation, as appropriate in the ED.
PATHOPHYSIOLOGY
To understand the possible origins of chest pain or discomfort, it is important to
review how this sensation is transmitted. Musculoskeletal pain is produced by
irritation of tissues and is transmitted through the sensory nerves. The stimulus is
carried through the nerve in the dermatomal or intercostal distribution to the
dorsal root ganglia, up the spinal afferents, and into the central nervous system
(CNS). This local, peripheral sharp pain can also be produced by primary dorsal
root irritation in the spine. Because of overlap of nerve distribution, pain may be
sensed in locations distal to the irritation. For example, the third and fourth
cervical nerves evoke pain as far caudally as the nipple line of the chest.
Tracheobronchial pain is transmitted by vagal afferents in the large bronchi and
trachea to fibers in the cervical spinal column. Dull, aching, or sharp pain is felt
in the anterior chest or neck. The irritation or sensation of cough is transmitted in
a similar fashion. Pleural pain arises in the pain-sensitive parietal pleura and then
travels through the intercostal nerves in the chest wall, giving rise to sharp, welllocalized pain. The visceral pleura is insensitive to pain. The intercostal or
phrenic nerves transmit diaphragmatic pain. Peripheral diaphragmatic irritation
may cause local chest wall pain because of the intercostal innervation. Central
