In contrast to Emergency Departments in which the clientele are mostly grown ups, patients with chest pain in the Pediatric Emergency Department have mostly benign causes. I wanted to review some of the findings associated with benign causes of non traumatic chest pain.
Tenderness to palpation of the chest wall
In children tenderness of chest chest wall very much suggests a musculoskeletal cause. These include costochondritis, muscle strain (get a history of recent exercise or ongoing cough), or slipping rib syndrome. This type of pain does quite well with rest and analgesics like Ibuprofen. I often analogize, and compare this pain to a sprained ankle. I also let parents and patients know that a sprain feels better when you rest t, but unfortunately completely “resting” your chest involves not breathing which is not recommended. Thus, this pain can last a little longer. I feel that this helps address some of the ongoing frustration.
Chest pain with fever and cough
If you clinically or radiographically diagnose a community acquired pneumonia recognize that many children will not have chest pain. It could be musculoskeletal due to coughing as well.
Chest pain with history of cough with exercise and/or at night
This suggests asthma – especially if they have a history of it. Chest tightness or difficulty breathing may be called “pain” by a child who doesn’t understand the difference.
Chest pain associated with heart burn
I find that many patients don’t actually know what heart burn feels like. Again, pain that occurs in the chest is often feared to be “from the heart.” Describing the pain and explaining why relationship to eating, laying down etc,. changes pain can go a long way. You should also ask about feeling of “food getting stuck” whether in the past or now. The feeling of having something stuck in the throat is known as the globes sensation. If patients cannot handle swallowing saliva or liquids an impacted foreign body is suspected. You should start with a plain film – though food is radiolucent – and either consult GI or consider a contrast esophogram. Patients with a history off recurrent impacted food suggests eosinophilic esophagitis.
Pain in the breast tissue
In females the differential includes fibrocystic disease, mastitis, pregnancy and gynecomastia and thelarche. Remember that boys heading into adolescence often get gynecomastia, which can lead to tender tissue.
History of stressful event and hyperventilation
To us, this is readily apparent. It’s a panic attack. Sometimes it’s mild pain that freaks the patient out and causes the period of hyperventilation etc,. You need to take a good history, provide reassurance, and most of all make the the patient and family know that they aren’t having a heart attack, pulmonary embolus pneumonia etc,. The ED is about what it is as well as what it isn’t.