Pediatric Chest Pain
- common complaint, rarely serious
- most common: musculoskeletal origin
- chronic chest pain: usually psychogenic
- chest pain with cardiac cause usually consistent over time
Clinical Findings Chest Pain
- past medical/fam hx of sudden death, heart disease, asthma, Marfan, SCD
- past sports activity
- previous trauma/muscle strains
- cardiac murmur, rubs, clicks
- point tenderness of one or more costochondral joints
- irregular heart rhythm
- SOB, coughing, wheezing
- rales, wheezing, tachypnea
Diagnostic Studies of Chest Pain
- febrile, pulm, cardiac condition : CXR
- exercise asthma: PFT
- rhythm disturbance - Holter monitor/stress test
- signs of CHD, percarditis, myocarditis - ECG
Management of Chest Pain
- reassurance after serious causes ruled out
- refer to pediatric cardiology for :
- chest pain that worsens with exercise
- chest pain that suggest angina
- positive findings on examination, ECG, CXR
- concerning personal/fam hx
Hypertension Definition
- for 13 and older BP exceeding 130/80
- for younger children as either systolic and/or diastolic BP greater than 95th percentile based on sex, age measured on 3 or more separate occasions
- pre HTN 90th percentile
Clinical Findings HTN
- body build/physique, overweight, metabolic syndromes
- dysmorphic features
- edema, pallor, flushing, skin lesions or tuberous sclerosis, SLE, neurofibromatosis
- upper/lower extremity central pulses
- fundi, thyroid, abd mass, flank bruit, visual acuity, facial palsy
- elevated BP
Diagnostic Studies HTN
- if less than 10 years with secondary HTN: CBC, ESR, CRP, UA/culture, electrolytes, BUN, creatinine, plasma renin, renal nuclear scans, renal US
- if renal vascular disease suspected, refer to pediatric nephrologist
- ECHO if cardiac involvement
Management of HTN
- ACEs, ARBs, BBs, CCBs, diuretics
- refer to nephrologist if HTN persistent
- if overweight, treat with lifestyle changes
What is infective endocarditis?
- bacterial/fungal infection
- more severe gingival inflammation, increased plaque, more microbes in children with SBE
Clinical Findings of Infective Endocarditis
- underlying structural abnormalities
- dental procedures/oral surgeries
- acute: high fever, myalgia, night sweats, arthralgias, HA, general malaise
- subacute: low grade fever, progressive, non specific symptoms
- embolization symptoms: hematuria, acute resp illness, splenomegaly, neurologic changes (stroke), petechiae, Osler nodes, splinter hemorrhages
Diagnostic Studies for Infective Endocarditis
- Clinical findings,
- blood cultures
- ESR, CRP, WBC elevated in acute stage
- ECHO: diagnostic
Management of Infective Endocarditis
- hospitalize; refer to pediatric cardiology
- treatment as soon as IE is suspected
- high doses of antibiotics for 4-6 weeks
Myocarditis and Cardiomyopathy
- myocarditis is rare; may go unrecognized and resolve spontaneously
- may progress to cardiomyopathy, death
- often caused by viral infection, or non-viral infection, medications, autoimmune or inflammatory disorders, toxic reactions
- inflammation: dilation of all cardiac chambers
Clinical Findings for Myocarditis and Cardiomyopathy
- pallor, cyanosis, mottled skin
- rapid, labored respirations
- tachycardia, gallop rhythm, muffled heart sounds, murmur, weak peripheral pulses
- hepatomegaly, JVD
** Infants: fever, irritability, pallor, diaphoresis, tachypnea, resp distress, poor feeding
** children: revent viral illness, lethargy, low grade fever, pallor, anorexia, exercise intolerance, rashes, palpitations, resp distress (late)
Diagnostic Studies for Myocarditis and Cardiomyopathy
- Refer to pediatric cardiologist if suspected, for CXR, ECG, ECHO, and other labs
Management of Myocarditis
supportive treatment; may take months, with lifelong follow-up
Pericarditis
An inflammation or other abnormality of the pericardium, the sac surrounding the heart
- excess fluid accumulates in the pericardial space and causes pericardium to distend
- the heart becomes compressed and limits its ability to fill
** Viral infection is the most common cause
Sinus Arrhythmia
variable HR; increases with inspiration; normal finding
Bradycardia
slow HR related to hypoxia, acidosis, increase ICP, abd distension, hypothermia, hypoglycemia, drugs, increased vagal tone
Complete AV block
congenital or acquired
Tachycardia
- sinus tachycardia (fever, anxiety, infection)
- SVT (pathologic)
- Long QT syndrome induced v-tach (genetic)
- PAC: in children and adults
- PVC: usually benign
Diagnostic Studies for Syncope
- abnormal ECG if cardiac
- orthostatic vital signs
- hemoglobin for anemia
- ECHO if history suggests cardiac
- treadmill for exercise-related syncope
Management of Syncope
- refer to pediatric cardiologist
- prevention with good hydration
