Pediatric emergency medicine trisk 1078 1078
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pain when no organic etiology and no psychological factors are present to explain
the pain. It is typically described as occasional short episodes of sharp chest pain
with or without exercise and no other associated symptoms. Physical examination
is completely normal and pain is not reproducible. Precordial catch syndrome or
“Texidor’s twinge” is a relatively frequent cause of chest pain in healthy
teenagers and young adults. It typically presents with an acute, sharp, welllocalized pain (often in the left substernal region) that has a “split second” onset,
is of short duration, worsened by deep inspiration, and usually occurs at rest or
related to exercise. It is often relieved by position change (sitting up straight)
which suggests that posture or ligamentous stretching of the supporting ligaments
of the heart may have a role but the true etiology is unknown. The physical
examination is normal without reproducible pain.
Other causes of chest pain include male adolescents with gynecomastia and
female patients with fibrocystic breast disease. Rarely, chest pain, pressure, or
shortness of breath, worse on supine position, will be associated with the
presentation of a mediastinal mass.
EVALUATION AND DECISION
Child With Thoracic Trauma
The first step in evaluation of the child with chest pain is to perform a thorough
history and physical examination. If the history is positive for a traumatic injury
or there is any evidence of trauma to the chest (see Chapter 115 Thoracic Trauma
), the patient requires rapid evaluation and may need immediate resuscitation as
well ( Fig. 55.1A ). Correction of cardiac or respiratory insufficiency may
diagnose and treat the cause of chest pain. Alveolar ventilation should be assessed
for adequacy and bilateral symmetry to distinguish acute respiratory failure from
hemothorax or pneumothorax. In children with chest trauma, tachycardia with
hypotension is generally caused by hypovolemia secondary to a hemothorax,
hemopneumothorax, or vascular injury. Reduced cardiac output and perfusion,
however, may also be secondary to a rhythm disturbance (from a myocardial
contusion or tension pneumothorax) or cardiac tamponade (which causes
muffling of the heart sounds and pulsus paradoxus). A discrepancy of the pulse or
blood pressure between the extremities points to aortic diseases, such as traumatic
avulsion or aneurysm. Ruptured esophagus and tracheobronchial disruption may
result from rapid deceleration injuries and may present with chest pain,
subcutaneous emphysema, respiratory distress, and hypotension.
