Pediatric emergency medicine trisk 1083 1083
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whose upper-extremity span exceeds his or her height and with overextensible
fingers.
During the examination, it is useful to relate normal findings to the child and
family because this reassurance often serves as the major “treatment” of selflimited or functional problems. Some families and patients are simply looking for
reassurance that the chest pain is not cardiac in origin. Concerning physical
examination findings such as fever, persistent tachycardia, persistent
hypertension, hypotension, pathologic murmurs, a gallop rhythm, abnormal
pulses, abnormal perfusion, hypoxia, and syncope warrant further investigation.
Pulse oximetry is a quick and inexpensive screen that is helpful in determining
the severity of any suspected pulmonary disease.
An EKG should be performed in almost all cases of chest pain if cardiac
disease is a possibility. Studies have shown that most cases of cardiac-related
chest pain can be picked up based on history, past medical history, concerning
family history, physician examination, and an EKG. The EKG will be normal in
almost all children with chest pain in which the physical examination is
unremarkable. However, it may show abnormalities to narrow down the
differential diagnosis. EKG findings may show signs of cardiac strain or ischemia
with valvular heart disease, diseases of outflow obstruction, or ischemia. Acute
cocaine exposure may present with classic signs of myocardial ischemia or
cardiomyopathy. A decreased QRS wave voltage and electrical alternans suggest
the presence of a pericardial effusion in the child with muffled heart sounds.
Decreased voltages, ST elevations, and T-wave abnormalities may also be seen in
diseases such as myocarditis and pericarditis. Heart block and arrhythmias, such
as atrial fibrillation and supraventricular tachycardia, can occur secondary to
anatomic, ischemic, inflammatory, and drug-induced conditions. These electrical
disturbances may be identified by careful evaluation of a rhythm strip. The S1 -Q3
-inverted T3 pattern may be seen on EKG evaluation in those with a pulmonary
embolism. Finally, concerning findings such as ventricular hypertrophy, QT
abnormalities and other pathologic EKG patterns can be found. Chest radiographs
(CXRs) are not necessary for all patients who present with nontraumatic chest
pain. They should be used selectively in patients in whom there is a clinical
concern for a pulmonary or cardiac cause of the chest pain. One may consider
obtaining a CXR in a patient with pulmonary symptoms such as cough or
shortness of breath, unilateral chest pain, associated shoulder pain, a concerning
medical history, or abnormal physician examination findings such as abnormal
breath sounds, unilateral breath sounds, a murmur, or abnormal vital signs such as
tachypnea or tachycardia. The CXR may reveal findings consistent with asthma,
