Chest Pain and Syncope

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Given what he has told you, what is the most likely cause of his chest pain?

Musculoskeletal pain and/or costochondritis is the most common cause of chest pain in the pediatric population. The boy in this scenario had sharp pain, worsened with inspiration and palpation. His vital signs were all stable. He had recently been lifting firewood, which likely caused some irritation to his chest wall.

2

What are other common causes of benign chest pain in the pediatric population?

• Psychogenic: Up to one-third of emergency room (ER) visits for chest pain will be related to some form of anxiety, panic attack, or somatization.

• Respiratory: Children may complain of chest pain with pneumonia, pleuritis, or while having an asthma exacerbation.

• Gastrointestinal: Children may complain of chest pain in the setting of reflux or esophageal spasm. More common in the pediatric population are foreign bodies—be sure to ask about choking or the possibility of a younger child putting something (i.e., toy, coin, battery, etc.) in their mouth.

• Precordial catch: This is a nonserious condition of unknown exact etiology that elicits sharp, stabbing pain, usually in a small area along the left sternal border, which is worse with breathing. The episodes of pain are usually sudden onset and brief and have no other associated symptoms.

• Idiopathic: There are some cases of chest pain in children in which we are unable to identify a specific cause.

Case: You arrive to a local high school to evaluate a 16-year-old boy who is complaining of chest pain. He was walking to class when he had sudden onset of pain. While sitting in class, he continued to have a dull ache along his left chest and subjective shortness of breath. On exam, he is very tall and thin. He is tachycardic and tachypneic and appears to be taking short, shallow breaths. Upon auscultation, he has diminished breath sounds along his left upper lung fields. RR is 24 and SpO ₂ is 91%.

3

What are you concerned about as the cause of his chest pain?

You should be most suspicious for a spontaneous pneumothorax given his age, physique, and physical exam. Serious causes of chest pain such as a pneumothorax will make up about 6% of ER visits. These may also include acute chest in a sickle-cell patient, pulmonary embolism, pneumomediastinum, asthma, and less commonly, aortic dissection in patients with collagen vascular disease such as Ehlers-Danlos, Turners, or Marfans syndrome. Congenital cardiac disorders, cardiomyopathies, myocarditis, pericarditis, and pulmonary hypertension should also be ruled out.

4

What questions should be part of your history taking when caring for a child with chest pain?

A good history and physical are usually enough to determine the likely cause of chest pain. Sample questions you should ask include the following: What does the pain feel like? Where is it located? How long have you had it? Is it constant or intermittent? How frequent is the pain? What were you doing when it started? Any associated symptoms? What makes it feel better/worse? Have you had this before? Have you been ill leading up to this?

• Medical history : Ask about past medical history and what medications they are taking.

• Personal history of cardiac disease, pulmonary disease, Kawasaki disease, sickle cell, cancer, coagulopathy, collagen vascular disease, diabetes, hypertension, hyperlipidemia, rheumatologic disease, and history of recent infection all have increased risk of chest pain caused by more serious etiology.

• Family history : Ask if family members have had cardiac disorders at a young age, sudden death, syncope, or prolonged QT syndrome.

• Social history : Ask about smoking or drug use (cigarette smoking, vaping, bath salts, cocaine, amphetamines, synthetic cannabis, and cough medicines); recent travel, trauma, surgeries, or periods of immobilization; sexual activity/possibility of pregnancy.

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