Pediatric emergency medicine trisk 1075 1075
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defect (VSD) is present. Eisenmenger syndrome is severe pulmonary
hypertension from an uncorrected congenital heart disease leading to cyanosis
from right-to-left shunting of blood. Isolated anatomic abnormalities such as ASD
have been known to present with chest pain and may or may not display the
classic findings of a hyperactive precordium, widely split fixed second heart
sounds, and both a systolic and diastolic murmur.
Unrecognized disease rarely causes isolated chest pain in a child who
otherwise appears well, but the physician should consider drug exposure (e.g.,
cocaine; methamphetamine; nicotine; beta-agonist abuse; the triptans;
combination
of
cold
medications
containing
chlorpheniramine,
dextromethorphan, and phenylpropanolamine; and herbal medications mentioned
previously). Although cardiac conditions are infrequent, attention should be paid
to diagnosing the rare patient with hypertrophic cardiomyopathy, angina, mitral
valve prolapse, or early pericardial or myocardial inflammation (see Chapter 86
Cardiac Emergencies ).
Pulmonary diseases are common and account for approximately 12% to 21%
of chest pain cases. A first episode of reactive airway disease should be suspected
when an associated night cough, history of wheezing, or family history of atopy is
present. There is a high incidence of exercise-induced asthma which often
presents with chest tightness, shortness of breath, and wheezing with exercise.
These historical features are important as the physical examination may be
completely normal during the ER visit. Infectious diseases of the respiratory tract
are associated with fever, malaise, cough, and coryza, and may involve several
family members simultaneously. Patients with pneumonia (see Chapter 99
Pulmonary Emergencies ) often present with tachypnea and hypoxia in addition
to fever and cough. Spontaneous (nontraumatic) pneumomediastinum and
pneumothorax may occur in patients with reactive airway disease, cystic fibrosis,
or as a result of barotrauma (i.e., Valsalva maneuver, forceful vomiting, or
coughing). The pain of a pneumothorax is often unrelenting and pleuritic in
nature. If the pneumothorax is moderate or large, then patients present with
significant respiratory distress and decreased breath sounds on the affected side.
Spontaneous (nontraumatic) pneumomediastinum is most often reported in male
adolescents without underlying lung disease and those with asthma. It appears to
occur with any activity that involves straining against a closed glottis. This is
thought to cause a rise in intra-alveolar pressure and subsequently a rupture of the
alveoli releasing air into the interstitial space. Air then dissects along facial planes
of the hilum into the mediastinum and neck. Those with spontaneous
pneumomediastinum present with substernal chest pain which frequently radiates
