Pediatric emergency medicine trisk 1066 1066
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individual evaluation must be started, however, with a broad differential diagnosis
in mind to ensure proper diagnosis and management of the child with chest pain.
Although studies range in estimating a cardiac cause for chest pain in a
pediatric patient, it is generally very low, <6%. A large more recent study of
pediatric patients with chest pain in a pediatric emergency setting found a cardiac
cause for chest pain to be 0.6%. Major categories include arrhythmias, anatomic
lesions, and acquired disorders such as myocarditis and pericarditis. Myocardial
ischemia is very rare in pediatrics but can present with typical unrelenting
substernal crushing chest pain with or without radiation to neck or arm,
diaphoresis, nausea, dyspnea, and syncope. Patients are usually in distress and
have physical examination abnormalities including pallor, diaphoresis, a gallop
rhythm, a heart murmur, and decreased peripheral perfusion. Myocardial
ischemia/infarction can occur as a result of a thrombosed coronary artery
aneurysm. These aneurysms, which occur as a sequela from Kawasaki disease,
have both insufficient laminar flow and areas of stenosis that become obstructed
via thrombosis leading to decreased myocardial perfusion. Case reports of
myocardial ischemia without risk factors in adolescents have been attributed to
vasospasm. Cocaine exposure can result in palpitations and coronary vasospasm
leading to ischemia, MI, arrhythmias, or cardiomyopathy. Patients with cocaine
toxicity are often anxious with confusion or combativeness and have significant
tachycardia and hypertension. Other toxins have cardiac effects. The herbal
medications aconite, ephedra, and licorice have also been implicated as the cause
of chest pain, congestive heart failure, arrhythmias, and MIs.
