approach to chest pain and syncope - macpeds.com · • develop a systemac approach to chest pain...
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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