Pediatric emergency medicine trisk 1085 1085
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of acute anemia and its cause. If an intra-abdominal source for chest pain from
diaphragmatic irritation is under consideration, a serum amylase may be obtained
in the workup of pancreatitis. The evaluation of a possible right-sided
subdiaphragmatic abscess would include liver function tests and further
delineation by ultrasound or CT scan. Findings of low PaO2 , EKG abnormalities,
and a positive D -dimer are suggestive of pulmonary embolism. This suspected
diagnosis requires the performance of a helical CT scan for confirmation.
Esophageal causes of chest pain may often be diagnosed clinically in the ED
with a trial of antacid therapy followed by H2 antagonist or proton pump
inhibitors. To confirm the findings of a hiatal hernia, esophagitis, or a radiolucent
foreign body, a barium study or endoscopy may be required. The clinician may
consider peak expiratory flow testing and/or therapeutic trial of bronchodilators
when asthma is suspected as the cause of chest pain.
Consultation with a pediatric cardiologist acutely for conditions such as
myocarditis, pericarditis, acute MI, or significant findings on EKG may be
necessary to assist with further workup and tests such as echocardiograms. The
decision to obtain an urgent echocardiogram depends on the clinical suspicion for
diseases such as myocarditis, pericarditis, pericardial effusion, or signs of
congestive heart failure.
Urgent consultation with a pediatric cardiologist should be considered for cases
where there is chest pain with palpitations, syncope or chest pain radiating to
back, jaw or left arm, patients with high-risk medical history, abnormal physical
examination findings such as sustained tachycardia, tachypnea, bradycardia,
noninnocent heart murmur, distant heart sounds, gallop, friction rub, increased
pulmonic component of heart sounds, edema or swollen extremities or abnormal
EKG findings such as low QRS voltages, ventricular hypertrophy, atrial
enlargement, AV block, prolonged QTc, (S1, Q3, inverted T3) pattern, PR
depression, ST-T segment changes, PVCs, WPW, or delta waves. Typically, these
patients should also receive a CXR as part of their evaluation. Follow-up with a
cardiologist, with exercise restriction until follow-up, may also be warranted for a
concerning history such as exercise-induced chest pain without other
cardiovascular symptoms, significant family history (see discussion under “Child
With No Thoracic Trauma”) that places the child at high risk for cardiopulmonary
disease, or borderline EKG findings that do not meet full criteria for being
abnormal.
Not infrequently, the workup of chest pain including tests such as an EKG or
CXR is helpful in allaying parental fears of cardiac disease. However, the
clinician should be aware that in some cases where a cardiac or respiratory
