by Mel Tavarez with Emily Willner on the Hot Seat
A 16 year old male presents with chest
pain. The pain began abruptly this
evening while watching a hockey game on TV, localized to his L chest, and sharp and crampy in quality. He has
associated SOB, L arm numbness and pleuritic CP. He denies palpitations. He feels better lying down. He is completely asymptomatic after arriving to the ED. Remainder of ROS is negative.
His PMH is significant for palpitations
for the past year and syncope x 1 this past month; he was evaluated by an outside
Cardiologist with reportedly normal EKG and ECHO. He was also hospitalized 3 wks ago for R knee cellulitis at
an OSH. His FH is significant for
a cardiac arrhythmia in his mother, hypertension in his father, MI in his MGF @
age 58 yrs, and past pericarditis in his brother but no congenital heart
disease, SIDS or sudden death.
Confidentially, he denies any stimulant, steroid or performance
enhancement drug use.
His exam was notable for VS including T 36.8, HR 68, RR 20,
BP 126/72, satO2 100% on RA and was otherwise completely normal. No murmurs were elicited with
squatting, he had no reproducible chest pain, and his neuro exam was intact.
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Okay, going to jump in. I have no idea what he has. It comes down to handling uncertainty; I don't know whether this is a concerning cardiac event or whether I think it is a benign (musculoskeletal) event. So, I have to choose. I think this is a benign event and will perform an ECG to check for an ongoing risk for arrhythmia because of his past palpitations and syncope. Then I would discharge him with return for sustained chest pain associated with shortness of breath, pain with exertion, syncope with exertion. If I were to decide that this is a serious event, then I would order an ECG, CXR, troponin and CK, with an eventual discussion with Cards.
ReplyDeleteI see a couple of things that are reassuring, but I am still a bit hesitant. The sudden onset of the pain and the character of the pain being sharp and crampy, don't bother me as much, but the shortness of breath, pleuritic chest pain, and arm numbness could be a problem. He also has a prior history to consider.
ReplyDeleteThe first thing I thought was, did he just get overexcited during the game and suffered a transient dysrhythmia maybe, or did he punch himself in the chest in his excitement, or could this be anxiety or GE reflux related. Given what organs live in that area (heart, lung, muscles, bones, esophagus, and blood), my differntials are: Cardiac - he is a bit too old for most congenital heart problems (dysrhythmia, precordial catch syndrome, pericarditis, although his pain improves with lying down, and angina-type pain/coronary vasospasm. Pulmonary (pneumothorax, pulmonary injury,although less likely with complete resolution of symptoms, or pleuritis, etc...), Good old costochondritis, anxiety, and finally, acid reflux. God knows what he is eating/drinking, while watching hockey. Those are my immediate thoughts.
I would order:
- EKG
- CXR mostly for the pulmonary reasons,even if I am not impressed on auscultation.
- CK MB, Troponin I
If he still has pain, I would try ibuprofen and ranitidine.
If my EKG and CXR are not revealing and the pain is resolved, I would consult cardiology, given his past medical history, which is not normal. If all clear by cardiology, I would send him back home and with his cardiology follow-up and call his PCP to make sure he gets seen soon. Just as Jennifer said, I would give him careful return to ED instructions. Chest pain with exertion, syncope especially during or right after exertion would be alarming signs. Given his history,I wonder if cardiology would echo him in the ED anyway before I let him go, so I would definitely ask them about that, unless I know what the previous echo showed.
I think I am being a bit conservative, since this is a hot seat case, but still, I think that is what I would do.
agree with Moh.
ReplyDeletechest pain in kids, even big kids, almost never impresses me unless there are vital sign abnormalities or truly concerning symptoms that go with it: syncope, palpitations, dyspnea, orthopnea, sweating, tingling. He has pretty much ALL of these, so it's hard not to do a cardiac "rule-out" on him. CXR to exclude pneumo, pericarditis, mediastinal mass. Troponins to exclude coronary insufficiency, acute MI. ECG because Priya loves them. Important to try and view his echo/cards eval. need to verify these were done by a pediatric cardiologist and not some random person. At the least he needs a holter +/- repeat echo.
the key will be if he continues to have symptoms in the ED. if he's still dyspneic or tachypneic, have to think about a PE. I like to get cards to echo these kids to look for right heart dysfunction, rather than contrast CT. he can go home with chest pain and occassional palpitations, but not with dyspnea, tachypnea, or orthopnea. He has every cardiac symptom in the book so i would put up a stink about making a cardiologist see this kid in the ED before he goes home.
outside of cardiac? who cares. a neuro exam to make sure he doesn't have true weakness in addition to tingling is important though.....
Not sure if I am missing something here but I feel we see so many patients with chest pain that have resolved by the time they arrive that I end up going through the motions of EKG +/-CXR with very little expectation of finding anything abnormal. If he is truly asymptomatic while in the ED with the vital signs as documented, not sure if I would do much more beyond EKG and CXR in real time. With that said, this is a 'hot seat' case so my antennas for a zebra are already up. Granted his history is not entirely normal (he has had intermittent palpitations and syncope x1, but he has also had an ECHO and EKG recently which were normal which is helpful and somewhat reassuring). My initial thoughts are his pain was sudden onset and non exertional which made me think of spontaneous pneumothorax occuring during the excitement of the hockey game, or could he have some cardiac coronary vaso-spasm that resulted in a transient ischemic cardiac event (digging back to my med school days, I remember Prinzmetal (sp?) angina as being a possiblity although I do not recall the demographic or the situations in which the chest pain occurs). So if this wasn't a hot seat case I would do both a CXR (looking for PTX, maybe look for subtle signs of hypervascularization sometimes seen with large PE), re-check an EKG (given his prior history of palpitations, looking for signs of ischemia) and if negative and patient back to baseline, close outpatient follow up, especially with Cardiology (would recommend a Holter). One other thought I thought is that the SOB/dyspnea at onset of chest pain made me initially concerned for PE but I would expect to see some tachycardia or persistent symptoms (SOB, chest pain etc), unless the emboli are tiny. So not sure I would go down the full PE work up right away unless he was still symptomatic. And lest anyone forget, consider checking a UTox since he might have been doing crack cocaine while screaming at the TV NHL players for going on strike for most of the season!
ReplyDeleteAgree with most of what's been said so far.
ReplyDeleteEKG, CXR (not standard in all chest pains, but given the various red flags as Dave mentioned). Wouldn't get cardiac enzymes at this time given no symptoms at all; a bad EKG would change my mind on that one.
One thing that struck me when I was reading this case -
As Jamil mentioned, hot seat cases have some zebras, and this guy is having a bad month! How many 16 yo males have had syncope, a hospitalization, and now neurologic symptoms in such a short time period. And the whole family has bad hearts. Just to throw in a zebra (to the more likely dx's already mentioned above) - thoracic outlet syndrome. Given that this patient had a lot of sx and then they spontaneously resolved, one thinks about arrhythmias as mentioned above, but also possibly an anatomic problem that is provocative. TOS can cause:
a. arm paresthesias from brachial plexus compression) - which can be exacerbated from putting your arm overhead for too long (which I could see from either watching a double-overtime hockey game - if your team is winning you're doing the overhand fist pump - if your team is losing you're reclining on the couch with arm abducted and hand holding head)
b. chest/neck/arm pain (TOS usually is not pleuritic in nature however)
c. TOS can also give you a PE from decreased blood flow leading to a clot. Maybe he had a mini-PE with chest pain and shortness of breath, but like the vast majority of tiny PE's, he spontaneously cleared it, and now has no symptoms.
Not likely TOS, but fun to think about (a "stretch" of a dx....literally!)
From the Hot Seat attending of the week...
ReplyDeleteThis case is interesting in that it takes a problem we see very frequently (the healthy child with chest pain) which is most often benign- and throws a few wrenches in it.
Chest pain is a common complaint in the pediatric emergency department, and in healthy children and teens, is most often benign. Chest wall pain, psychogenic causes, asthma, GI/reflux, and pain with no identifiable cause are the most common diagnoses. The key to evaluating these patients is to identify the small minority with serious pulmonary (pneumonia, pneumothorax, pulmonary embolus) or cardiac (ischemia, arrhythmia, pericarditis/effusion, myocarditis) conditions.
When evaluating the child with chest pain, the history and physical exam are critical in guiding testing and evaluation. This patient’s immediate history sounds highly suspicious for a chest wall source, such as “precordial catch”. His pain is resolved and he has a normal exam and normal vital signs. While he doesn’t have reproducible pain, there is nothing else of concern on his exam.
His past history is where things get more interesting: he has a family history of arrhythmia (it would help to know what kind) AND pericarditis, and a recent cardiac evaluation for syncope/palpitations. He also had a recent hospitalization, which might have caused him some immobilization. This would prompt me to ensure I examine his calves for swelling/tenderness and specifically ask about family history of blood clots, since as a teen boy he has none of the other common risk factors for thromboembolic disease. If there were no family history of clotting and no LE findings, I would not pursue thromboemobolic disease given his normal HR, Pox and RR and resolved pain.
As for his cardiac history, while I find it reassuring that he had a reportedly normal echo elsewhere, there are enough red flags in his history (syncope, recurrent palpitations) and his family history that I would definitely screen him with an EKG (all the while wishing I had his cardiac workup results in front of me!).
The history and vitals do not suggest an ongoing cardiac ischemic process (resolved pain, no tachycardia, normal BP, normal cardiac exam), so I would not pursue that diagnosis specifically. Finally, exam does not suggest asthma, pnemothorax, or pneumonia (no ongoing pain or dyspnea, normal Pox, no fever or history of fever or cough). That said, I’ve seen healthy teens with small spontaneous pnemothorax have VERY normal exams and VS, so while I’m inclined to say I wouldn’t Xray him- I also might if there were anything just a bit off.
If his EKG (and CXR) were normal, I’d send him home with very detailed return precautions, and ask the family to call his cardiologist to let them know of the ED visit. If those tests were normal, I wouldn’t do blood work or consult cardiology. If his pain recurred while in the ED or there were abnormalities on EKG, I would.
My most likely diagnosis if EKG/CXR are normal would be precordial catch- a.k.a. “Texidor’s twinge” for those who like eponyms. It is a sudden sharp pain, most commonly in the left anterior chest, which is increased with breathing or moving. It is very intense, can cause quite a lot of anxiety and distress as it is difficult to take normal/deep breaths, and lasts 30 seconds to several minutes. The cause is unknown, but may be a brief intercostal muscle spasm or come from the parietal pleura. That said, this is the Hot Seat, so we’ll see how the story unfolds….