Managing the Grandparent with Chest Pain: Advice for Emergency Pediatricians

Managing the Grandparent with Chest Pain: Advice forEmergency PediatriciansLynn Williams, BA, MBBCh, FRCS (Ed), FFAEM,*Martin Culshaw, MBChB, MRCP (UK), FFAEMy

222

Faced with a grandparent, really any older adult, complaining of chest pain, the emergencypediatrician is not required to have an in-depth knowledge of adult internal medicine toeffectively perform an initial evaluation and commence investigation and treatment. Theapproach to these patients requires the recognition of chest pain as a potential hallmark of alife-threatening illness, including myocardial infarction. A standardized approach to anyadult with chest pain should include the efficient delivery of basic diagnostic and therapeuticinterventions that should be available even in a specialized pediatric institution. Timelytransfer to an adult facility to complete the assessment and to exclude life-threateningcauses is essential to maximize the outcome of these patients.Clin Ped Emerg Med 6:222-228 ª 2005 Elsevier Inc. All rights reserved.

KEYWORDS chest pain, acute coronary syndrome, aortic dissection, tension pneumothorax,pericarditis

*Emergency Department, Queen’s Medical Centre, NG7 2UH, Notting-

ham, UK.

yAcute Medicine Department, Queen’s Medical Centre, NG7 2UH,

Nottingham, UK.

Reprint requests and correspondence: Lynn Williams, BA, MBBCh,

FRCS (Ed), FFAEM, Emergency Department, Queen’s Medical

Centre, NG7 2UH, Nottingham, UK.

(E-Mail: [email protected])

Accompanying a sick or injured child to the Emer-gency Department (ED) can be upsetting and

stressful for any caregiver. In these circumstances, agrandparent may complain of symptoms that are new orare related to a known illness. Chest pain is one suchsymptom and may result from disease in a variety of bodysystems. In addition, pain severity does not necessarilyreflect the seriousness of the underlying disease process.

A grandparent with chest pain presents a challenge tothe emergency pediatrician who may not have greatexperience or confidence in caring for ill adults and whomay not have immediate access to a specialist in adultemergency medicine or internal medicine. The increasingincidence of teenage pregnancies in recent decades meansthat bgrandparentsQ may not always be elderly. The rangeof potential causes of chest pain to consider in thedifferential diagnosis is, therefore, much greater. Even inthe finest adult treatment facility, the cause of chest painmay not always be quickly determined in the ED.

Etiology of Chest Pain in theGrandparentAs in children, chest pain in adults ranges in se-

riousness from innocent to life-threatening. Chest pain

1

accounts for 5% of adult ED visits and is therefore a

more common presenting complaint in that population

compared with children. Faced with a grandparentcomplaining of chest pain, the emergency pediatrician

must assume that the cause is life-threatening until

proved otherwise, and arrange to transfer the patient to

an adult facility for further assessment at the earliest

opportunity. Common causes of chest pain, both life-

threatening and non–life-threatening, are shown in

Table 1. The most critical causes of adult chest pain

that should be considered by the emergency pediatri-cian follow below.

Acute Coronary SyndromeAcute coronary syndrome (ACS) describes a clinical

presentation suggestive of acute myocardial ischemia

522-8401/$ - see front matter ª 2005 Elsevier Inc. All rights reserved.

doi:10.1016/j.cpem.2005.09.008

Table 1 Causes of adult chest pain.

Cardiac chest painACSMyocardial infarctionUnstable angina

Aortic dissectionChronic anginaCocaine abuseMyocarditisPericarditis

Noncardiac chest painAsthmaChest wall infectionChest wall injuryCholecystitis/gallstonesCocaine abuseCostochondritisHeartburn/indigestionHerpes zoster infectionMusculoskeletal disordersPancreatitisPeptic ulcerPneumoniaPneumothoraxPsychogenicPESickle cell disease

Managing the grandparent with chest pain 223

and encompasses myocardial infarction and unstable

angina. It is the commonest life-threatening cause of

acute chest pain presenting to the ED. The diagnosis ofACS is based on symptoms including the nature and

site of the chest pain, risk factors, electrocardiogram

(ECG) findings, and biochemical markers such as

troponin. Table 2 demonstrates that the nature of

acute chest pain and associated risk factors may be

Table 2 Nature of chest pain and risk factors.

Nature of Pain

ACS Retrosternal IncreasCrushing, tight, gripping,sharp, burning

Men yoequal dover 70

Radiates to any of arms,shoulders, neck, ears,throat, back, epigastrium

SmokinDiabet

Aortic dissection Retrosternal and back HypertTight, gripping, tearing Men oRadiates to any of arms,shoulders, neck, ears,throat

PregnaMarfan

PE Either side of chest ImmobPleuritic Recent

CoaguPericarditis Retrosternal Recent

Sharp, pleuritic HIV/AIPneumothorax Either side of chest Injury

Pleuritic Cocain

unhelpful in distinguishing ACS from other life threat-

ening causes.

Approximately, 2 million people are admitted to the

hospital in the United States each year for evaluation of

acute chest pain. Of these, about 30% are diagnosed as

having unstable angina or a myocardial infarction.

Myocardial infarction is the leading cause of death inadults in the United States. Up to 8% of patients

presenting with a myocardial infarction are inappropri-

ately discharged from EDs, and the mortality in this

group is approximately double that of patients who are

admitted [1].

Myocardial Infarction

This is a common cause of adult chest pain. One in 6 adult

patients with chest pain has a myocardial infarction, and

the risk is higher in elderly patients [2]. The emergency

pediatrician does not need to be an expert in ECG

interpretation to pursue this diagnosis. Up to 50% of

patients with a myocardial infarction do not have

diagnostic changes on the initial ECG; thus, distinguish-

ing between a diagnosis of unstable angina and amyocardial infarction is difficult. Serial ECGs over sev-

eral hours may show the evolution of ST-segment

changes diagnostic of myocardial infarction. The pres-

ence of ST-segment changes, including ST elevation

greater than 1 mm in 2 leads (Figure 1), mandates rapid

transfer to an adult facility for early fibrinolytic therapy,

ideally within 6 hours of the onset of pain. Similarly, left

bundle-branch block (Figure 2) may be new and resultfrom myocardial infarction.

Unstable Angina

The likelihood of myocardial infarction and death is

increased by the development of unstable angina. This

Risk Factors

ing age Hypertensionunger than 70 years,istribution of sexesyears

Previous ACS

g

Family history

es

Cocaine and amphetamineabuse

ension Cocaine abuselder than 60 yearsncy’s syndrome

ilization Malignancytrauma Pregnancy

lopathy Previous thromboembolismviral or bacterial illness Previous ACS

DS Cardiac instrumentationPreexisting lung disease

e abuse

Figure 1 Anterior myocardial infarction. ST-segment elevation of greater than 1 mm in leads I, aVL, and V1-4, with

reciprocal changes in leads a and aVF.

L. Williams, M. Culshaw224

may present as new angina triggered by exertion (eg,

bringing an injured child to the ED), as known angina

that is increasing in frequency and duration or not

Figure 2 Left bundle-

responding to nitroglycerin, or as angina at rest in the

ED waiting room. Unstable angina can be precipitated by

anxiety and hypertension.

branch block.

Figure 3 Electrocardiogram findings in PE: S wave in lead I and

aVL more than 1.5 mm, indeterminate axis, S1Q3T3 pattern,

elevated ST segment in lead aVR, ischemic-appearing ST

segments + inverted T waves in the inferior and anteroseptal

leads.


Aortic DissectionThis most commonly occurs in the thoracic aorta, withblood dissecting between the vessel intima and media,

generally as a result of an intimal tear. It is initially

misdiagnosed in up to 40% of cases and is diagnosed at

postmortem in up to one third. In-hospital mortality is

approximately 30%. There are no clinical features that

accurately distinguish aortic dissection from ACS.

The diagnosis should always be considered in the

presence of acute chest pain, which may be associatedwith back pain. The pain may be out of proportion to

other clinical findings and require large amounts of

analgesia. Hypertension may be present, and the systolic

blood pressure may be significantly higher in the left arm

than in the right if the dissection extends into the origin

of the brachiocephalic trunk. The ECG, which usually is

normal or shows nonspecific changes, is often not helpful

in making this diagnosis.

Pulmonary EmbolismIn 90% of cases, the source of a pulmonary embolism

(PE) is a deep vein thrombosis in a lower limb. Risk

factors include recent injury or surgery, immobility,

malignancy, hypercoagulability, and a history of throm-

boembolism. For untreated PE, the mortality is approx-

imately 30%.

No specific symptoms or signs are diagnostic of a PE,and the ECG is not helpful in 85% of cases. In a minority of

patients, the ECG may show an S wave in lead I (SI), a Q

wave in lead III (Qa), a T wave in lead III (Ta) (Figure 3),

or a right bundle-branch block (Figure 4). The clinical

presentation of PE ranges from mild dyspnea, with or

without chest pain, to cardiovascular collapse. The

diagnosis should be considered in any grandparent with

pleuritic chest pain, dyspnea, and tachypnea. The goldstandard for diagnosis is pulmonary angiography or axial

computerized tomography of the pulmonary arteries [3,4].

PericarditisInfectious causes of pericarditis include viruses, bacteria,

mycobacteria, and fungi. Inflammation of the pericardium

can occur during a viral illness or, afterward, as a result of

an autoimmune response to the viral illness. Sometimes,

pericarditis occurs in the presence of HIV infection.

Symptoms of pericarditis may include chest pain, dysp-

nea, and fever. The chest pain may be positional and may

worsen with inspiration. Electrocardiogram changes

include depression of the PR segment and elevation of

the ST segment in all leads except aVR and V1, where

reciprocal changes are seen (Figure 5).

Tension PneumothoraxThis can occur in a grandparent who puts their grand-

child’s clinical assessment ahead of their own when bothhave been injured. It can also occur if a grandparent,

perhaps at the younger end of the age spectrum, is a

cocaine smoker. Cocaine use by any route can also result

in myocardial infarction.

Evaluation of a Grandparent withChest Pain in the Pediatric EDThe history is the most significant part of the evaluationbecause there are often no abnormal clinical signs. Even

after a comprehensive history and physical examination,

with supporting investigations such as an ECG, the

diagnosis may still prove to be elusive to the emergency

pediatrician, and later to the general emergency physician

or specialist in internal medicine. It is reassuring to

remember that most patients presenting to an ED with

chest pain do not have significant disease. It is essential,however, to maintain a high index of suspicion that the

cause of chest pain could be life-threatening.

HistoryEstablishing the history of a grandparent’s chest pain

follows the same principles as in children. History taking

must be concise yet comprehensive, and include past and

concurrent medical history, recent surgery or trauma,

risk factors for cardiovascular disease, social history(which may be relevant to safe discharge), and use of

both prescription and nonprescription drugs.

The nature and location of chest pain can indicate the

underlying cause in some patients, but in most cases,

the diagnosis will remain unclear (Table 2). Asso-

ciated symptoms, including back pain, cough, diapho-

resis, dyspnea, and nausea and vomiting, should be

elicited. A history of collapse or loss of consciousnessshould be sought.

Physical Examination

General Appearance

This assessment ranges from healthy, through varying

degrees of anxiety, to pale, ill, or collapsed. Diaphoresis

Figure 4 Right bundle-branch block.


may reflect anxiety, severity of the pain, or cardiovas-

cular compromise. Ill appearance should always causeimmediate concern for the presence of a life-threat-

ening disorder.

Vital Signs

Remember that children are not small adults and adults are

not large children. Physiological parameters that are

Figure 5 Electrocardiogram f

normal in children may reflect serious hemodynamic

instability in adults. A pulse rate more than 100 perminute represents tachycardia in an adult and could result

from a cardiac problem, such as pericarditis. A weak

thready pulse is a sinister finding and indicates impending

cardiac failure or deteriorating cardiac function.A blood pressure of 90/60 mm Hg is certainly accept-

able in a 5-year-old but may represent cardiogenic shock,

indings in pericarditis.


secondary to a myocardial infarction, in a 55-year-oldgrandparent complaining of central crushing chest pain.Manual recording of the blood pressure may be necessaryin the ill grandparent with chest pain, because automateddigital recording can be inaccurate.

Hypertension associated with chest pain, with adiastolic blood pressure greater than 90 mm Hg, couldbe the result of anxiety, pain, or serious pathology. Asystolic blood pressure difference of greater than 20 mmHg between the upper limbs can result from aorticdissection. Radial-femoral delay may also be found inaortic dissection.

A respiratory rate of 30 may be normal in a smallchild, but in a 60-year-old grandparent with pleuriticchest pain, it may result from hypoxia in the presenceof a PE. A low oxygen saturation, which does notimprove with supplemental oxygen, could suggest thediagnosis of a PE. The grandparent with pericarditis orpneumonia, for example, can be febrile, but thetemperature may be low in the seriously ill. It is alsoimportant to recognize that normal vital signs in agrandparent with chest pain do not exclude a life-threatening condition.

Cardiorespiratory System

Examination is frequently normal and may not be helpful

toward making the diagnosis. Signs of injury to the chest

wall may point to the presence of a pneumothorax, or a

pulmonary or cardiac contusion resulting in chest pain,before further examination is completed. Paradoxical

filling of the neck veins in inspiration, Kussmaul’s sign,

suggests a diagnosis of PE or pericarditis, but is a rare

finding in clinical practice.

Crackles or wheezes in the lung fields must be

interpreted according to a grandparent’s presenting

symptoms and history. Cardiac failure compromising

oxygenation can point to a provisional diagnosis ofmyocardial infarction, especially if associated with hypo-

tension. Heart murmurs are unlikely to be helpful in

reaching a diagnosis. A pericardial rub, best heard at the

lower left sternal border, with the patient sitting forward

in full expiration, is pathognomonic of pericarditis.

Management of a Grandparentwith Chest Pain by theEmergency PediatricianThe early management of the adult who presents with

chest pain should result in the following interventions.

OxygenSupplemental oxygen should be commenced in all

patients suspected of having a life-threatening cause of

their pain. High concentrations of oxygen are beneficial

to most patients and can be life saving. A minority of

patients with chronic obstructive pulmonary disease

depend on hypoxia to stimulate respiration. The oxygen

can then be titrated according to respiratory rate and

effort, level of consciousness, and oxygen saturation,

which should be maintained around 90% [5].

Intravenous AccessBlood samples should be obtained when intravenous

access is established. These should include a completeblood cell count and electrolytes. Subsequent evaluation

may also be aided by obtaining a baseline creatine kinase

or troponin level. A sickle test should be performed if

previously undiagnosed sickle cell disease is suspected of

causing chest pain. A clotting screen and a cross-match

sample are essential if aortic dissection is suspected. If the

children’s hospital does not routinely perform some of

these baseline studies, the labeled blood samples canaccompany the patient to the receiving adult ED. It is

imperative that such samples be clearly identified

and timed.

Pain ManagementWhen ACS is suspected, reversal of cardiac ischemia bynitroglycerin can provide effective pain control. Patientswith a history of angina may have tried their ownnitroglycerin without effect. If not, 0.4 mg of nitro-glycerin should be given sublingually, if available, andrepeated every 5 up to 15 minutes as needed. Nitro-glycerin is also beneficial in the presence of hypertension.It is important for the emergency pediatrician toremember that administration of nitroglycerin within24 hours of the patient taking sildenafil (Viagra) orsimilar agents is likely to precipitate hypotension andshould be avoided.

Intravenous morphine, titrated to patient need inincrements of 2 mg, should be considered for those with

severe chest pain. Morphine is typically a fast-acting and

effective intervention for severe pain, particularly in those

who fail to achieve relief with nitroglycerin. Morphine

can also be beneficial in the presence of concurrent

pulmonary edema. Pediatricians should be aware that a

recent published study has raised concerns about the

safety of the routine use of morphine in ACS, advisingthat pain relief be primarily addressed with nitroglycerin

[6]. An anti-inflammatory drug such as ibuprofen should

be considered if pericarditis is suspected.

Therapy Beneficial to OutcomeAntiplatelet therapy in the form of aspirin (325 mg)

reduces mortality independently of thrombolytic therapy

and should be given at the earliest opportunity to all

patients suspected of having ACS and not currently taking

salicylates [7]. As aspirin is rarely used in pediatric care, it

might not be readily available in the pediatric ED. For this

PEARLS1. A high index of suspicion is essential to managing a

grandparent with chest pain.

2. Anticipate, do not procrastinate—chest pain could

be life-threatening.

3. Expertise in reading an ECG is not necessary.

4. In ACS, the ECG can be normal.

5. Aspirin reduces mortality in ACS.

6. Aspirin and nitroglycerin should be available foradult use in a pediatric ED.

7. Certain baseline studies obtained at the outset may

become very helpful to the physicians taking care of

the patient later, even if not immediately helpful.


scenario alone, aspirin should be stocked in all EDs,

including those in specialized pediatric facilities, so as not

to delay its administration. Intravenous furosemide (20

mg) can improve oxygenation and should be considered

when acute cardiac failure is present.

Appropriate MonitoringAn initial ECG should be obtained promptly upon any

adult’s presentation with any chest pain. Cardiac mon-

itoring should be commenced at the earliest opportunity

to detect arrhythmias and should be continued during

transfer to an adult facility. If transfer is delayed, the ECG

should be repeated every 30 to 60 minutes. Pulse,

respiratory rate and blood pressure, including differential

blood pressures in the arms if aortic dissection is

suspected, should be recorded every 15 minutes, and

oxygen saturation recorded continuously.

Chest RadiographyThe chest radiograph is frequently not helpful in ex-

plaining the cause of chest pain. A widened mediastinum

is seen in less than 50% of patients with aortic dissection.

Other abnormalities, including aortic calcification and

dilatation of the thoracic aorta, are nonspecific in aiding

the diagnosis. An unsuspected pneumothorax or pneumo-

nia may be seen on chest x-ray. Obtaining a chest

radiograph should not delay transfer to an adult ED.

Rapid Safe Transfer to an Adult EDThe patient should be transported by paramedics in anadvanced life support–equipped vehicle to a nearbycapable adult ED for further assessment and treatment.

Initiation of Basic and Advanced Life Supportin the Event of Cardiac ArrestAlgorithms for basic and advanced life support in anadult, recommended by the American Heart Association[8], should be followed. The algorithms are the same asthose for an older child, over 8 years, and require thesame drugs and equipment, which should be readilyavailable in the pediatric ED.

SummaryThe etiology of acute undifferentiated chest pain in agrandparent may be difficult to establish, even for

a specialist in adult emergency care or internal medi-cine. Faced with such a patient, the emergency pedia-trician should focus on measures that provide afoundation for excluding life-threatening illness andoptimizing outcome. Such measures, as discussed in thispaper, should be well within the capability of allemergency pediatricians.

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3. Stein PD, Athanasoulis C, Alavi A, et al. Complications and validity of

pulmonary angiography in acute pulmonary embolism. Circulation

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4. Remy-Jardin M, Remy J, Wattinne L, et al. Central pulmonary

thromboembolism: diagnosis with spiral volumetric CT with the

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