Pediatric emergency medicine trisk 1076 1076
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to the neck and is worse with deep inspiration and position changes, subcutaneous
crepitus, Hamman sign (crunching heart sounds), dysphagia, and dysphonia. This
diagnosis must be distinguished from pneumothorax, pericarditis, and esophageal
perforation.
Pleural effusions can cause chest pain associated with decreased breath sounds
and dullness to percussion on physical examination. Pleurodynia, often secondary
to coxsackievirus B infection, causes sharp chest pain, fever, and a friction rub.
Aspiration of a foreign body into the trachea or esophagus may occur without
such history in a toddler or even in an older child, and approximately 50% of
these children may complain of chest pain. Foreign bodies lodged in the airway
often present with chest pain, cough, decreased breath sounds, and unilateral
wheezing. However, auscultatory findings may be unimpressive despite a positive
history.
Although pulmonary embolisms (see Chapter 99 Pulmonary Emergencies ) are
rare in children, they can present with pleuritic chest pain, cough, hypoxia,
hemoptysis, dyspnea, respiratory distress, and the sense of impending doom.
Usually this condition is associated with risk factors such as obesity, oral
contraceptive use, pregnancy, collagen vascular disease, nephrotic syndrome,
cigarette smoking, recent surgery, immobility, trauma (particularly spinal injury),
a positive family history, a hypercoagulable condition (known or unknown), or
prior cardiorespiratory problems. Finally, children with sickle cell disease can
develop a vasoocclusive crises resulting in acute chest syndrome.
GI diseases account for approximately 4% to 7% of pediatric patients with
chest pain. Diseases include gastroesophageal reflux, esophagitis, gastritis, ulcer
disease, and rarely esophageal rupture or spasm. History is important with regard
to the relationship of the symptoms to meals and body position. Pain of
gastroesophageal reflux is typically described as burning, worse in the recumbent
position, related to eating, and improved with antacid or hydrogen ion blocker
therapy. The physical examination is usually normal or positive for epigastric
tenderness. Foreign bodies in the GI tract can cause chest pain, drooling,
dysphagia, and odynophagia. The history often uncovers this diagnosis and
radiography may be helpful. Spontaneous esophageal perforation (Boerhaave
syndrome) is secondary to transmitted increased pressure against a closed glottis
most often seen with vomiting but also straining, coughing, defecation, seizure,
childbirth, or forceful nose blowing. Presentation includes symptoms of chest
pain, crepitus, pneumomediastinum, and hematemesis to hemorrhage and shock.
Mackler triad includes vomiting, chest pain, and subcutaneous emphysema. There
are case reports of adolescents diagnosed with diffuse esophageal spasm via
