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Chest Pain Evaluation Algorithm

Initial Assessment

flowchart TD
    A[Child/Adolescent with<br/>Chest Pain] --> B{Hemodynamically<br/>Stable?}

    B -->|No - Unstable| C[Emergency Protocol<br/>ABCs, IV, O2, Monitor]
    B -->|Yes - Stable| D{Red Flags?}

    C --> C1[ECG immediately]
    C --> C2[Consider:<br/>PE, Pericarditis w/ tamponade,<br/>Aortic dissection, MI]

    D -->|Yes| E[Full Cardiac Workup]
    D -->|No| F[Detailed History]

    E --> G{Cardiac Cause<br/>Identified?}
    G -->|Yes| H[Treat Underlying<br/>Cardiac Condition]
    G -->|No| I[Consider Other<br/>Etiologies]

    F --> J{History Suggests<br/>Cardiac?}
    J -->|Yes| E
    J -->|No| K[Non-Cardiac Workup]

    K --> L{Musculoskeletal?}
    L -->|Yes| M[Reassurance +<br/>NSAIDs PRN]
    L -->|No| N{GI/Respiratory?}
    N -->|Yes| O[Appropriate<br/>Treatment]
    N -->|No| P{Psychogenic?}
    P -->|Yes| Q[Counseling +<br/>Follow-up]
    P -->|No| R[Idiopathic -<br/>Reassurance]

    style C fill:#ff6b6b
    style E fill:#ffd93d
📋 Text Version (if diagram doesn't render) **Chest Pain Initial Assessment** 1. **Hemodynamically Stable?** - **NO** → Emergency Protocol (ABCs, IV, O2, Monitor, ECG) → Consider PE, tamponade, dissection, MI - **YES** → Red flags present? 2. **Red Flags?** - **YES** → Full cardiac workup → Cardiac cause? → Treat or consider other etiologies - **NO** → Detailed history → Suggests cardiac? → If yes, cardiac workup; if no, non-cardiac workup 3. **Non-Cardiac Workup:** - Musculoskeletal → Reassurance + NSAIDs - GI/Respiratory → Appropriate treatment - Psychogenic → Counseling - Idiopathic → Reassurance

Red Flags Requiring Urgent Evaluation

Red Flag Concern
Exertional chest pain HCM, AAOCA, myocarditis
Associated syncope Arrhythmia, structural disease
Family history SCD Inherited cardiomyopathy, channelopathy
Known heart disease Progression, new complication
Acute onset, severe PE, dissection, tamponade
Fever + chest pain Pericarditis, myocarditis
Radiation to back Aortic pathology
Marfanoid habitus Dissection, pneumothorax
Recent Kawasaki disease Coronary artery aneurysm

Etiology by Frequency in Children

pie title Causes of Pediatric Chest Pain
    "Musculoskeletal" : 30
    "Idiopathic" : 25
    "Respiratory" : 15
    "GI" : 10
    "Psychogenic" : 10
    "Cardiac" : 5
    "Other" : 5
📋 Text Version (if diagram doesn't render) **Causes of Pediatric Chest Pain:** - Musculoskeletal: 30% - Idiopathic: 25% - Respiratory: 15% - GI: 10% - Psychogenic: 10% - **Cardiac: 5%** - Other: 5%

Key Point: Cardiac causes account for <5% of pediatric chest pain presentations

Diagnostic Approach by Suspected Etiology

Musculoskeletal (Most Common)

Characteristics: - Reproducible with palpation - Worse with movement, breathing - Specific point tenderness - History of activity/trauma

Conditions: - Costochondritis (Tietze syndrome) - Muscle strain - Precordial catch syndrome (Texidor's twinge) - Slipping rib syndrome

Management: - Reassurance - NSAIDs for pain - Activity modification - No cardiac workup needed if classic presentation

Cardiac Causes (Rare but Important)

Cause Presentation Workup
Pericarditis Sharp, positional, fever, rub ECG, echo, inflammatory markers
Myocarditis Exertional, dyspnea, fatigue ECG, troponin, echo, CMR
Arrhythmia Palpitations, racing ECG, Holter, event monitor
HCM Exertional, family history Echo, ECG
AAOCA Exertional, syncope Echo, CT/MRI, stress test
Coronary (Kawasaki) History of KD Echo, stress test, CT angio
Aortic stenosis Exertional, syncope Echo

When to Get an ECG

Always Get ECG If: - Exertional chest pain - Associated syncope or palpitations - Family history of SCD or cardiomyopathy - Known heart disease - Any red flag present - Abnormal cardiac exam

ECG Not Necessary If: - Classic musculoskeletal features - Reproducible with palpation - No red flags - Normal cardiac exam

When to Get an Echocardiogram

Indications: - Abnormal ECG - Abnormal cardiac exam (murmur, rub) - Family history concerning for cardiomyopathy - Exertional symptoms with red flags - Marfanoid features - Known or suspected structural heart disease - Suspected pericarditis/myocarditis

Specific Conditions

Precordial Catch Syndrome

Most Common Benign Cause in Adolescents

Features: - Sudden onset, sharp, localized pain - Left precordial or substernal - Lasts seconds to minutes - Worse with deep breathing (patients breathe shallowly) - Resolves spontaneously - No associated symptoms - Normal exam

Management: - Reassurance (benign, self-limited) - No workup needed - No treatment required - Resolves with age

Pericarditis

Diagnostic Criteria (2 of 4): 1. Pleuritic chest pain (sharp, worse supine) 2. Pericardial friction rub 3. ECG changes (diffuse ST elevation, PR depression) 4. Pericardial effusion

Initial Workup: - ECG - Echo - CRP, ESR - Troponin (to rule out myopericarditis) - CBC - Consider: viral panel, ANA, TSH

Myocarditis Suspicion

When to Suspect: - Exertional chest pain + fatigue - Heart failure symptoms - Recent viral illness - Elevated troponin - ECG changes - LV dysfunction

Workup: - ECG - Troponin (usually elevated) - BNP - Echo - Cardiac MRI (gold standard)

Disposition Algorithm

flowchart TD
    A[Chest Pain Evaluation<br/>Complete] --> B{Diagnosis?}

    B -->|Cardiac - Acute| C[Admit]
    B -->|Cardiac - Stable| D[Close Cardiology F/U]
    B -->|Non-Cardiac| E{Needs Treatment?}

    E -->|Yes| F[Treat + PCP F/U]
    E -->|No| G[Reassurance +<br/>PRN F/U]

    C --> C1[Pericarditis/Myocarditis]
    C --> C2[Significant arrhythmia]
    C --> C3[New cardiomyopathy]

    D --> D1[Structural disease]
    D --> D2[Concerning history]
    D --> D3[Abnormal testing]
📋 Text Version (if diagram doesn't render) **Disposition Algorithm** - **Cardiac - Acute** (pericarditis/myocarditis, significant arrhythmia, new cardiomyopathy) → Admit - **Cardiac - Stable** (structural disease, concerning history, abnormal testing) → Close cardiology F/U - **Non-Cardiac** → Needs treatment? → Treat + PCP F/U or Reassurance + PRN F/U

Key Teaching Points

  1. <5% of pediatric chest pain is cardiac - but must identify the few who are
  2. Reproducible pain with palpation strongly suggests musculoskeletal cause
  3. Exertional chest pain is the most important red flag
  4. Precordial catch syndrome is extremely common and benign
  5. ECG is indicated when any red flag is present
  6. Reassurance is the treatment for most pediatric chest pain
  7. Family anxiety may exceed clinical concern - address directly