Pediatric emergency medicine trisk 1074 1074
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palpitations, and physical examination findings such as a gallop rhythm and a
murmur secondary to mitral valve insufficiency.
Inflammatory conditions such as pericarditis and myocarditis can present with
chest pain and systemic symptoms. Pericardial disease includes pericarditis,
pericardial effusions, and cardiac tamponade. Pericarditis often presents with
fever, a stabbing chest pain that improves with sitting up and leaning forward,
respiratory distress, a friction rub, and distant heart sounds. Pericarditis and
pericardial effusions can restrict outflow leading to neck vein distention and in
severe cases of tamponade, pulsus paradoxus (see Chapter 86 Cardiac
Emergencies ). The presentation of myocarditis can be more subtle with mild
chest pain and fatigue for several days followed by the development of fever,
dyspnea, and worsening chest pain. The examination often shows tachycardia (or
bradycardia when severe), orthostatic changes not improved by fluid
resuscitation, pulsus paradoxus, and a gallop rhythm. Both pericarditis and
myocarditis are usually associated with a preceding viral illness. Endocarditis is
most often seen in children with a history of congenital heart disease but can
present in those with no known predisposing condition. Patients are often ill
appearing with a history of prolonged fever and may have signs of embolization.
Other illnesses that can present with carditis include rheumatic heart disease and
Kawasaki disease.
Chest pain associated with mitral valve prolapse is controversial. Studies have
shown that mitral valve prolapse is not more common in those with chest pain
than in the general population and other etiologies of the chest pain may exist in a
patient with this condition. However, chest pain in patients with mitral valve
prolapse may be secondary to papillary muscle or left ventricular endocardial
ischemia. A midsystolic click and late systolic murmur should be found on
physical examination. Pain secondary to mitral valve prolapse should be
considered only when no other etiology may be found.
Patients with connective tissue disorders such as Marfan syndrome have the
potential to develop aortic dilation, aortic dissection, and rupture. Symptoms of
aortic dissection/rupture include generalized distress with unrelenting severe
chest pain, decreased cardiac output, dyspnea, and often abdominal pain.
Children who present with chest pain days to months after cardiac surgery
should be evaluated for signs of pericardial effusion known as postpericardiotomy
syndrome. Patients with pulmonary hypertension may present with exercise
intolerance, palpitations, and syncope. The resultant right ventricular dilatation
may be found on physical examination as a narrowed second heart sound,
hepatomegaly, and cyanosis if an atrial septal defect (ASD) or ventricular septal
