Chest pain in a pediatric emergency department: clinical assessment and management reality in a third-level Portuguese hospital

Abstract

Chest pain in children and adolescents is a common complaint in the emergency department (ED), being mostly benign. A thorough patient history and physical examination should be enough in most cases for its proper management. Regarding non-cardiac chest pain, anxiety plays an important role.

Methods: Retrospective analysis of all admissions in a pediatric ED of a Portuguese third-level hospital with a chief complaint of chest pain between January and December 2018. Chi-square test was used to compare different etiologies, considering a significance level of 5%.

Results: A total of 798 visits were included: 53.6% girls, 80.8% adolescents (mean age: 13years old). According to the Pediatric Canadian Triage and Acuity Scale, 77.7% was prioritized as level IV: less urgent; 65.3% reported associated symptoms including dyspnea (31.8%), cough (18.2%), and palpitations (16.1%). In physical examination, 45.5% had alterations: 62.8% with chest wall tenderness. Further investigation was done in 84% of patients: 62.4% electrocardiograms (altered in 14.7%), 52.6% chest radiographies (altered in 17.1%) and 8.9% cardiac biomarkers (altered in 12.7%). The 3 main causes of chest pain were musculoskeletal (33%), idiopathic (24.4%) and psychogenic (21.6%), with 1.1% of cardiac etiology. Less than 3% needed hospital admission and 18.9% were oriented to an outpatient consultation. 7.1% readmissions reported. When compared to other causes as a group, psychogenic chest pain presented a statistically significant association with female sex, adolescence, psychiatric antecedents, previous stressful event, and normal physical examination. Of these, <30% were oriented to a pedopsychiatry/psychology consultation.

Conclusions: Opposing to the low priority level in triage, benign diagnosis found, and low hospital admissions, there was a high percentage of complementary diagnostic tests performed with few altered results. In psychogenic chest pain there was a low postdischarge referral. The authors highlight the importance of clinical algorithms to reduce unnecessary tests performed and readmissions and improve orientation and follow-up, particularly in psychogenic etiology.

Keywords: anxiety; chest pain; idiopathic chest pain; musculoskeletal chest pain; pediatric emergency department; psychogenic chest pain.

Figure 1

Physical examination alterations.

Figure 2

Complementary diagnostic tests performed and altered results.

Figure 3

Causes of cardiac chest pain.