Pediatric emergency medicine trisk 1080 1080
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Many children with thoracic injuries but no respiratory distress also complain
of chest pain. Although a careful examination is mandatory in an effort to exclude
significant intrathoracic trauma, the cause of the pain usually resides in the chest
wall: contusions of the soft tissues or rib fractures. A history of significant trauma
even in the absence of cardiovascular abnormality dictates that radiographs and
an electrocardiogram (EKG) be obtained. Injury to the heart including myocardial
contusions and acute rupture of cardiac structures can occur during rapid
deceleration and compression-type injuries. Pulmonary injuries include
contusions, pneumothoraces, and hemothoraces. These injuries may present with
subtle physical examination findings. Patients have presented with chest pain
following blunt trauma that was subsequently complicated by the development of
posttraumatic VSD and pseudoaneurysm.
Finally, the clinician should consider child abuse if rib fractures are seen in a
young infant. In older children, a predisposing cause for fracture (i.e., bone cyst
or tumor) should be sought.
Child With No Thoracic Trauma
As discussed above, the first step in evaluation of the child with chest pain is to
perform a thorough history and physical examination assessing for
cardiorespiratory instability. A thorough history including a complete review of
symptoms, social history, and family history should be obtained. The description
of chest pain should include quality, intensity, location, frequency, and duration as
well as its relationship to exercise, food intake, position, or trauma. Chest pain
relieved by leaning forward is consistent with pericarditis, while that which is
worsened by reclining may represent pericarditis, gastroesophageal reflux, or
hiatal hernia. The review of symptoms should be broad including systemic
symptoms such as fever, fatigue, weight loss, diaphoresis, or intolerance to
exercise; cardiac symptoms such as palpitations, heart racing, dizziness, or
syncope; pulmonary symptoms such as dyspnea, cough, or wheezing; and GI
symptoms such as vomiting, dysphagia, abnormal taste in the mouth, or
abdominal pain. In general, chest pain that is acute in onset, described as crushing
sternal pain with or without radiation to left arm or neck, awakens a patient at
night or is associated with exertion, syncope, fever, fatigue, dyspnea, decreased
exercise tolerance, or palpitations is concerning and demands a more extensive
evaluation.
Next, the physician should inquire about a history suggestive of prior
cardiorespiratory disease such as asthma, cystic fibrosis, congenital or structural
heart conditions as well as high-risk past medical histories of collagen vascular
disease, connective tissue disorders, hyperlipidemia, malignancy, thrombophilia,
