The McMaster at night

Pediatric Curriculum

Pediatrics in Review Vol. 31 No. 1 2010 pp. e1 -e9

Approach to

chest pain and

syncope

in adolescents

Objectives

•  CanMedsmedicalexpert•  Understandthecommondifferen5aldiagnosisofchest

painandsyncopeinadolescents•  Developasystema5capproachtochestpainandsyncope

inadolescents•  CanMedscollaborator

•  Understandproperu5lityofinves5ga5ons•  Understandindica5onforreferralandadmission

Background

•  Chestpaininchildrenisoneofthemostcommonreasonsforanunscheduledvisittotheprimarycarephysician’soffice.

•  Chestpainissecondonlytoheartmurmurforreferraltoapediatriccardiologist.

•  Chestpaininchildrenusuallyisnotcausedbyaseriousdisease,incontrasttochestpaininadults.

•  Syncopeisaverycommondisorderwithabimodalincidenceinchildrenandadolescents,peakinginfemalesaged15-19years.

•  Uptoone-thirdofthepopula5onwillexperiencesyncopeatsomepointinlife,and15%willexperiencesyncopebeforeage21.

The Case

•  17yo, Female, previously healthy. •  Presented at ER with sudden onset of chest pain, SOB,

nausea, vomiting. •  She was dizzy, almost fainted, was caught by her friend.

History

What would you ask?

History

•  O-teaching hip-pop dancing, sudden onset •  C-getting worse, had to stop dancing •  D-10-15 minutes •  P- retrosternum •  Q-tightness, “somebody sitting on the chest” •  R-no •  S-8/10 •  T-exertion

History

•  Associated symptoms •  SOB •  N/V •  Dizziness, no LOC •  No cough, wheeze •  No palpitation •  No sweaty, trembling, tingling, chocking

History

•  Prior to that •  Stress, math test in the morning •  Poor sleep the night before

•  No fever, chill •  No URTI •  No dehydration

History

•  PMHx •  Palpitation 11-13 yo, •  Syncope x7 d/t pain or vomiting •  No asthma, sickle cell disease •  No Kawasaki’s disease, hypercholesterolemia •  No OCP •  No smoking, drinking, drug abuse •  No mood disorder

•  Meds- nil •  Allergy- nil •  Immunization- UTD

History

•  FHx •  Maternal uncle bicuspid aortic valve, stroke at 37 •  Paternal uncle epilepsy in 30’s •  No congenital heart defect, no sudden death,

arrhythmia, hypercholesterolemia

•  HEADSSS Hx •  No family stressors. •  Good student. Active dancer. •  No risky behaviors.

Physical Exam

What would you look for?

Physical Exam

•  Vital signs, orthostatic BP-WNL •  Chest

•  No tenderness, no reproducible chest pain. •  Equal air entry, no wheeze.

•  CVS •  I-quiet precordium. •  A-normal regular heart beats, no clicks or murmurs,

no gallops. •  Normal femoral and peripheral pulses.

•  GI •  No HSM, no tenderness.

Workup

What would you order?

Workup

•  B/W-CBC,CRP,extendedlytes,cardiacenzyme•  CXR•  ECG•  ECHO•  Holter•  Exercisestresstest

Differential Diagnosis Non-cardiacCausesofChestPaininChildren

PediatricsinReviewVol.31No.12010pp.e1-e9

Differential Diagnosis CardiacCausesofPediatricChestPain

Heatillness*

Anaphylaxis*

Vasovagal(neurocardiogenic)syndrome,includingsitua5onalsyncope(eg,cough,mictura5on,haircombing,blooddraw,intramuscularinjec5on,oremo5onalstress)¶

Breathholdingspell¶

Orthosta5chypotensionduetovolumedeple5on(hemorrhage,dehydra5on,pregnancy,anorexianervosa)¶

Drugeffectsortoxicexposure(eg,clonidine,typicalan5psycho5cagents,carbonmonoxide,ethanolintoxica5on)¶

Hypoglycemia*

Condi5onsthatmimicsyncope

Seizure

Migrainesyndromes

Hystericalfaint

Hyperven5la5on

Inten5onalstrangula5on(eg,the"chokinggame")

Narcolepsy

Commoncondi5onsHeatillness*

Anaphylaxis*

Vasovagal(neurocardiogenic)syndrome,includingsitua5onalsyncope(eg,cough,mictura5on,haircombing,blooddraw,intramuscularinjec5on,oremo5onalstress)¶

Breathholdingspell¶

Orthosta5chypotensionduetovolumedeple5on(hemorrhage,dehydra5on,pregnancy,anorexianervosa)¶

Drugeffectsortoxicexposure(eg,clonidine,typicalan5psycho5cagents,carbonmonoxide,ethanolintoxica5on)¶

Hypoglycemia*

Condi5onsthatmimicsyncopeSeizure

Migrainesyndromes

Hystericalfaint

Hyperven5la5on

Inten5onalstrangula5on(eg,the"chokinggame")

Narcolepsy

Primarycardiacelectricaldisturbances

LongQTsyndrome*

Brugadasyndrome*

Familialcatecholaminergicpolymorphicventriculartachycardia*

ShortQTsyndrome*

Preexcita5onsyndromes(suchasWolffParkinsonWhite)*

Bradyarrhythmias(completeatrioventricularblock,sinusnodedysfunc5on)*

Structuralcardiacabnormali5es

Hypertrophiccardiomyopathy*

Coronaryarteryanomalies*

Arrhythmogenicrightventriclulardysplasia/cardiomyopathy*

Valvaraor5cstenosis*

Dilatedcardiomyopathy*

Pulmonaryhypertension*

Acutemyocardi5s*

Congenitalheartdisease*

PrimarycardiacelectricaldisturbancesLongQTsyndrome*

Brugadasyndrome*

Familialcatecholaminergicpolymorphicventriculartachycardia*

ShortQTsyndrome*

Preexcita5onsyndromes(suchasWolffParkinsonWhite)*

Bradyarrhythmias(completeatrioventricularblock,sinusnodedysfunc5on)*

Structuralcardiacabnormali5esHypertrophiccardiomyopathy*

Coronaryarteryanomalies*

Arrhythmogenicrightventriclulardysplasia/cardiomyopathy*

Valvaraor5cstenosis*

Dilatedcardiomyopathy*

Pulmonaryhypertension*

Acutemyocardi5s*

Congenitalheartdisease*

Indication for admission

•  Evidence of cardiovascular disease (ie, heart failure or arrhythmia)

•  An abnormal ECG (ie, a conduction abnormality) •  Chest pain with syncope •  Syncope with cyanosis •  Apneic or bradycardic spells that resolve only with

vigorous stimulation •  Abnormal neurologic findings •  Orthostatic hypotension that does not resolve with fluid

therapy

Test Your Knowledge

•  Please highlight the history and physical exam of patient with chest pain.

The Answer

Test Your Knowledge

•  Please list red flags for cardiac syncope.

The Answer

•  Palpitation and syncope triggered by exercise, emotion and startle.

•  History of congenital heart disease or Kawasaki's disease.

•  Personal or family history of deafness. •  Family history of sudden death,

unexplained MVA or drowning. •  Family history of cardiomyopathy. •  Abnormal physical exam or ECG.

Summary

•  95-98%ofchestpainarenotcardiac,bethorough•  Syncopecanbelifethreatening,ECGforallthepa5ents•  Developasystema5capproach•  Inves5ga5onsmayhaveverylowyield,beselec5ve•  Beawareofredflags,referoradmitifindicated

Fin