This guideline is in draft form only and should not be used to guide clinical management
Clinical Practice Guideline
Chest Pain
Author: Stuart Lewena
Version: [ Click here and type version no. ]
Date: 18 February 2016
See also: [ type hyperlinks to other guidelines here ]
Background
The majority of children presenting with chest pain as a primary complaint do not have a
cardiac or other serious underlying disorder. The priorities of assessment are to firstly
exclude these disorders or provide appropriate emergency treatment and to
subsequently form a diagnosis and management plan for the remainder of cases. Common
causes of paediatric chest pain in patients without risk factors for serious disease
include:
 Musculoskeletal strains
 Respiratory infections with or without cough
 Asthma exacerbations
 Upper GI or biliary disease
 Pericardial “catch” – short sharp pains experienced by healthy teenagers and young
adults thought to be produced by stretch of pericardial supporting ligaments.
 Anxiety, idiopathic – many children have no organic diagnosis made.
The presence of certain risk factors increases the probability of potentially serious
causes:
Risk factors for serious or life threatening conditions
Risk factor
Major chest trauma
Prior cardiac disease or surgery
Hypercoaguable states
(primary clotting disorders, neoplasms,
pregnancy, contraceptive pill use,
prolonged immobility or post surgery,cental
venous catheters, connective tissue
disease, past history or strong family
history of thromboembolic disease)
Sickle cell disease
Chronic respiratory disease
Kawasaki disease
Familial hyperlipidaemia syndromes
Cocaine or stimulant use
Connective tissue disease
Condition to consider
Pneumothorax, haemothorax, cardiac or
pulmonary contusion, mediastinal
disruption.
Myocardial ischaemia, arrhythmia,
pericarditis, pericardial effusion.
Pulmonary embolus
Acute chest syndrome
Pneumothorax
Coronary aneurysm and myocardial
ischaemia
Myocardial ischaemia
Myocardial ischaemia
Pericarditis and pericardial effusion, aortic
dissection
This guideline is in draft form only and should not be used to guide clinical management
Assessment
The most important step in initial assessment is identifying signs of cardiorespiratory
distress:
 Dyspnoea, tachypnoea, increased work of breathing
 Hypoxia
 Abnormal pulse or blood pressure
 Poor perfusion
 Distended neck veins, muffled heart sounds
 Depressed mental state
For further specific assessment of underlying cause see chest pain algorithm.
Key examination and basic investigation findings that may be identified in uncommon
serious conditions are presented in the table below:
Condition
Myocardial ischaemia
Pericarditis
Pericardial effusion
Pulmonary embolus
Aortic dissection
Findings
Abnormal pulse or blood pressure, arrhythmia, ST segment
elevation or depression, raised troponins
Positional pain, pericardial rub, widespread ‘saddle-shaped’ ST
elevation
Hypotension, distended neck veins, muffled heart sounds,
pulsus paradoxus, globular enlarged cardiac silhouette on CXR
Tachypnoea, tachycardia, hypoxia, haemoptysis, non specific
ST and T wave changes in anterior chest leads most common
ECG finding, ‘classical’ S1Q3T3 pattern is uncommon. May see
minor CXR abnormalities – usually normal
Differential limb BP’s, CXR findings include: widened
mediastinum, left pleural cap and deviated trachea and main
stem bronchi. Signs of myocardial ischaemia or pericardial
tamponade if complicated by these events.
Management

Trauma patients and those with signs of cardiorespiratory compromise should be
resuscitated along general principles prior to considering more directed management
(see resuscitation guideline).

Chest pain algorithm provides a guide for further management including special
investigations, consultation and referral.

All patients with positive risk factors for serious conditions should be discussed
with senior staff prior to final disposition.

Despite the rarity of serious underlying conditions, many children and parents have
significant anxiety surrounding possible cardiac disease. Specific reassurance is an
important part of management.
This guideline is in draft form only and should not be used to guide clinical management