Pediatric emergency medicine trisk 1065 1065
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diaphragmatic stimulation travels by the phrenic nerve, with the distribution of
pain referred to the shoulder of the affected side.
The esophagus appears to be more pain sensitive in its proximal portion. Pain
is transmitted by afferents to corresponding spinal segments, with resultant
anterior chest or neck pain. The pericardium is innervated by portions of the
phrenic, vagal, and recurrent laryngeal nerves, as well as by the esophageal
plexus. This appears to give rise to various sensations, including chest or
abdominal pain, dull pressure, and even referred angina-like pain.
Other mediastinal structures, such as the aorta, have pain fibers in the
adventitia of the vessel wall. They transmit pain through the thoracic sympathetic
chain to the spinal dorsal roots, giving rise to sharp, and variably localized chest
pain. Cardiac pain probably is transmitted by a number of routes, including the
thoracic sympathetic chain and the cardiac nerves through the cervical and
stellate ganglia. It has been proposed that pain arises from abnormal ventricular
wall movement and stimulation of the pericardial pain fibers. These routes
account for the sensation of cardiac chest pain as pressure or crushing substernal
pain or as sharp pain in the shoulder, neck, or arm.
DIFFERENTIAL DIAGNOSIS
A differential diagnosis of chest pain in children is included in Table 55.1 . In the
case of trauma, cardiac or pulmonary compromise may arise from direct injury to
the heart, great vessels, or lung (see Chapter 115 Thoracic Trauma ). Most chest
pain in the nontraumatized child is caused by acute respiratory disease,
musculoskeletal injury, anxiety, or inflammation ( Table 55.2 ). Often, the
physician does not make a causative diagnosis of the chest pain and calls it
nonspecific or idiopathic in origin. Occasionally, this idiopathic chest pain may
be unrecognized organic disease, such as gastroesophageal reflux disease. Chest
pain in children usually occurs without associated cardiorespiratory signs or
symptoms, often as an acute or chronic problem. By the time of the ED visit,
frequently the pain has resolved. Although much less frequent, chest pain in
association with cardiorespiratory distress demands immediate attention. Table
55.3 lists the life-threatening causes of chest pain by disease and mechanisms for
decompensation. Chest pain in the dyspneic or cyanotic patient most often stems
from a respiratory problem, such as pneumonia, asthma, pleurisy, or
pneumothorax. Rarely, severe chest pain in an acutely ill child results from
myocardial infarction (MI) due to aberrant coronary vessels, cocaine abuse,
Kawasaki disease, hyperlipidemia, or other underlying cardiac diseases (aortic
stenosis, an acute arrhythmia, cardiomyopathy, or pericardial disease). Every
