Pediatric emergency medicine trisk 1081 1081
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myopathies, Kawasaki disease, or a prolonged febrile illness. It is also important
to determine if there is a family history of sudden or unexpected death,
hypercholesterolemia,
hyperlipidemia,
pulmonary
hypertension,
hypercoagulability disorders, early cardiovascular disease, cardiomyopathy or
other sudden death related predisposing heart conditions such as long QT
syndrome, short QT syndrome, Brugada syndrome, which could also place the
patient at higher risk of a cardiopulmonary cause of the chest pain.
The social history should include recent immobilization, stressors, cigarette,
and drug use including prescription medications such as oral contraceptives,
stimulants such as cocaine, and herbal medications. In addition, it may be helpful
to determine the patient’s perception of the pain and how it is affecting their life.
Research has shown that approximately one-third of children with chest pain have
missed school because of their symptoms and approximately half of children with
chest pain associate this pain as a problem with their heart.
Children with respiratory illnesses, such as asthma or cystic fibrosis are at risk
for pneumothorax, acute respiratory failure from mucous plugging or
pneumonitis, and acute pulmonary hypertension. In the child with a history of
cardiac arrhythmias (see Chapter 86 Cardiac Emergencies ), congenital heart
disease, cardiac surgery, or pericardial effusions, chest pain may signal an
exacerbation of the underlying problem.
In the absence of prior cardiopulmonary disease or trauma, the approach must
be directed toward unmasking evidence for any of the serious cardiorespiratory
illnesses listed in Table 55.3 .
Figure 55.1 is a general approach to the differential diagnosis of atraumatic
chest pain based on some physical examination findings. It is not all inclusive and
further investigation is often needed. A thorough examination usually uncovers
evidence of the cardiac and respiratory causes of chest pain. The clinician must
carefully assess the vital signs looking for fever, tachycardia, bradycardia,
tachypnea, bradypnea, hypertension, hypotension, and hypoxia. The patient may
be well appearing with no apparent distress or ill appearing with significant
distress. Concerning signs of the general appearance include cough, drooling,
retractions, lethargy, pallor, or cyanosis. The physical examination in asthma
shows a prolonged expiratory phase of respiration, variable degrees of chest
hyperinflation, and wheezing accentuated by a forced expiratory effort. However,
auscultatory findings, such as crackles or wheezing, may be minimal when
obstructive pulmonary disease is moderately severe and a history of foreign body
aspiration should also be sought with new-onset wheezing. Fever, hypoxia,
tachypnea, decreased breath sounds, and/or crackles suggests pneumonia whereas
