Syncopal episodes may require no more than reassurance to the patient and family. If the episodes have a significant impact on daily activities, further evaluation may be indicated. An electrocardiogram (ECG) should be obtained with attention to the QTc and PR intervals (see Chapter 139). Although reassurance and increasing fluid and salt intake may be adequate to treat most cases of syncope, medical management is sometimes indicated.
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Chest pain in the pediatric patient often generates a significant amount of patient and parental concern. Although chest pain is rarely cardiac in origin in children, common knowledge about atherosclerotic heart disease raises concerns about a child experiencing chest pain. Most diagnosable chest pain in childhood is musculoskeletal in origin. A significant amount
Anxiety, hyperventilation
Ischemia (coronary artery abnormalities, severe AS or PS, HOCM, cocaine) Infection/inflammation (myocarditis, pericarditis, Kawasaki disease) Dysrhythmia
Abnormalities of rib cage/thoracic spine Tietze syndrome Slipping rib Tumor
Pleurisy Pneumothorax, pneumomediastinum Pleural effusion Pulmonary embolism
AS, Aortic stenosis; HOCM, hypertrophic obstructive cardiomyopathy; PS, pulmonary stenosis.
remains idiopathic, however. Knowledge of the complete differential diagnosis is necessary to make an accurate assessment (Table 141-1).
Assessment of a patient with chest pain includes a thorough history to determine activity at the onset; the location, radiation, quality, and duration of the pain; what makes the pain better and worse during the time that it is present; and any associated symptoms. A family history and assessment of how much anxiety the symptom is causing are important and often revealing. A careful general physical examination should focus on the chest wall, heart, lungs, and abdomen. A history of chest pain associated with exertion, syncope, or palpitations or acute onset associated with fever suggests a cardiac etiology. Cardiac causes of chest pain are generally ischemic, inflammatory, or arrhythmic in origin.
Tests rarely are indicated based on the history. A chest x-ray, electrocardiogram (ECG), 24-hour Holter monitoring, echo-cardiogram, and exercise stress testing may be obtained based on history and examination. Referral to a pediatric cardiologist is based on the history, physical examination findings, family history, and, frequently, the level of anxiety in the patient or family members regarding the pain.
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Cardiac dysrhythmias or abnormal heart rhythms are uncommon in pediatrics but may be caused by infection and inflammation, structural lesions, metabolic abnormalities, and intrinsic conduction abnormalities (Table 142-1). Many pediatric dysrhythmias are normal variants that do not require treatment or even further evaluation.
Sinus rhythm originates in the sinus node and has a normal axis P wave (upright in leads I and AVF) preceding each QRS complex. Because normal rates vary with age, sinus bradycardia and sinus tachycardia are defined based on age. Sinus arrhythmia is a common finding in children and represents a normal variation in the heart rate associated with breathing. The heart rate increases with inspiration and decreases with expiration, producing a recurring pattern on the electrocardiogram (ECG) tracing. Sinus arrhythmia is normal and does not require further evaluation or treatment.
Intoxication (cocaine, tricyclic antidepressants, and others) Antiarrhythmic agents (proarrhythmic agents [quinidine]) Sympathomimetic agents (caffeine, theophylline, ephedrine, and
Electrolyte disturbances (↓↑K+, ↓↑Ca2+, ↓Mg2+) Cardiomyopathy Thyrotoxicosis Uremia Pheochromocytoma Porphyria Mitochondrial myopathies