Wong Pediatric Chest Pain

Chest pain in children is rarely cardiac in nature. Cardiac issues in kids rarely present with chest pain.

Asthma and reactive airway disease are common causes of chest pain.

Pediatric coronary arteries rarely get stented because the stented artery will not grow with the child. Consequently the child who has a coronary stent, as they mature and grow, will have a fixed size coronary artery due to the stent and have coronary insufficiency the rest of their life.

Anomalous coronary artery can result in coronary insufficiency. Anomalous coronaries branch off the wrong part of the aorta and branch off at an acute angle. Both result in reduced flow.

Kawasaki’s aneurysms can cause chest pain.

Cocaine and marijuana can cause pediatric chest pain.

Arrhythmias can be a cause of chest pain.

Pericarditis and myocarditis. Myocarditis is a high risk diagnosis that can have serious morbidity and mortality. Think about myocarditis with in patients with fever, tachycardia, and recent viral illness associated with their chest pain.

Hypertrophic cardiomyopathy can cause chest pain. The hypertrophic septum can block the LV outflow tract and decrease coronary flow. HOCM causing chest pain will have significant murmur.

Aortic stenosis or pulmonary stenosis are valvular causes of chest pain and will have a murmur.

Aortic dissection can cause chest pain. It is exceedingly rare in kids. Consider it in kids with Marfan’s, Ehlers Danlos, or family hx of Marfan’s Ehlers-Danlos, or other connective tissue disorder

The high-risk diagnoses for pediatric chest pain are anomalous coronary artery, hypertrophic cardiomyopathy and myocarditis. Anomalous coronary artery can be very difficult to diagnose. You won’t be able to definitively diagnose it in the ED if the patient does not have EKG changes. If their pain has resolved the EKG changes may have resolved as well. Consider anomalous coronary artery if the patient has exertional chest pain. Hypertrophic cardiomyopathy causes syncope or sudden death more commonly than chest pain. If it is causing exertional chest pain there will be a prominent murmur. Myocarditis may have tachycardia, EKG changes, signs of heart failure, elevated troponin, or recent history of viral illness.

The incidence of PE in pediatric patients is increasing. There is a bimodal age distribution (neonates and teenagers). Screen with a d-dimer level over 0.75.

Congenital heart disease, Long QT and Brugada do not present with chest pain.

Myocarditis is the highest risk diagnosis that if sent home is most likely to have a bad outcome. Myocarditis can be identified by abnormal EKG, tachycardia, and elevated troponin. The patient may have an elevated troponin or history of recent viral illness.

ACA Guideline for kids age 5-18: Ask about exertional chest pain. It is a Red Flag historical finding. Ask for family hx of cardiomyopathy, early CAD, and sudden death. Perform a physical exam for murmur and lung sounds. Get an EKG.

Get an echo for exertional chest pain patients, patient with high risk past medical or family history, murmur, or abnormal EKG. Echo may not need to be emergent. Asymptomatic patients in the ED can be discharged home with activity limitation and pediatric cardiology follow up.

Holter monitor will capture every beat for 24 hours. Event monitors are worn for 30days and capture 15 min recordings retrospectively from the time the patient voluntarily triggers the device when having some symptoms.

Kids with psychogenic chest pain referred to cardiology usually end up getting extensive workups with echo, event monitors and stress tests.

Ahmad/Johns Oral Boards

Case 1. 23 yo female presents with chest pain and shortness of breath. Dad notes a change in patient’s mental status. Patient is tachycardic and hypotensive. EKG shows electrical alternans

Diagnosis was pericardial tamponade due to autoimmune disease. Treatment is IV fluid resuscitation and consulting for or performing pericardiocentesis.

Case 2. 39 yo male presents with a seizure. Blood sugar is normal. Patient received IM midazolam in the prehospital phase with continued seizure. IV Ativan in ED did not terminate seizure. Patient had recent history of positive PPD for employment screening. Patient has been taking isoniazid. Patient was treated with standard medications for status epilepticus with no improvement. B6 (pyridoxine) was given next which terminated seizure. Diagnosis was seizures secondary to isoniazid.

These symptoms may progress to the three classic features of acute isoniazid overdose: seizures, metabolic acidosis, and protracted coma.46,47 Seizures typically follow acute isoniazid ingestions of greater than 20 to 30 milligrams/kg. Isoniazid-induced seizures are generalized tonic-clonic in nature and are often refractory to standard anticonvulsive therapy with benzodiazepines and barbiturates. The mechanism for isoniazid-induced seizures is a functional deficiency of pyridoxine (vitamin B6) and inhibition of the synthesis of γ-aminobutyric acid, the primary CNS inhibitory neurotransmitter. Seizures with therapeutic doses of isoniazid have been reported in patients,48 presumably due to very low vitamin B6 levels.49 Although the metabolic acidosis that accompanies isoniazid-induced seizures is likely due to motor activity, the lactic acidemia may not resolve as rapidly as with other more typical epileptic seizures.

Consider isoniazid overdose in patients with refractory seizures.44 Isoniazid-induced seizures are treated with a combination of benzodiazepines and pyridoxine. The dose of pyridoxine is a gram-for-gram equivalent to the amount of isoniazid ingested.50 For patients who ingest an unknown quantity of isoniazid, the recommended dose of pyridoxine is 5 grams IV in adults and 70 milligrams/kg (maximum 5 grams) in pediatric patients. Pyridoxine may be administered at a rate of approximately 1 gram IV every 2 to 3 minutes until the seizures stop or the maximum dose has been given. After the seizures have ceased, the remainder of the pyridoxine dose should be given over the following 4 to 6 hours to limit recurrent seizures.

Adequate single-dose therapy of pyridoxine should be effective to stop most seizures, but patients who do not receive adequate pyridoxine dosing may have repeat seizures. Pyridoxine may also assist in reversing isoniazid-induced comas. (Tintinalli 8th edition)

Case 3. 79 yo male patient presents with abdominal pain. Abdominal exam showed peritonitis.

Diagnosis was perforated viscous causing abdominal pain. Treatment is IV crystalloids, IV antibiotics, and surgical consultation.

Davis/Miner/Mullen/Lorenz BounceBacks

For ETOH dependent patients who are withdrawing, follow the CIWA score and if it is increasing consider higher level of care dispo such as step-down. If a patient has a history of prior ICU admit consider step-down admission.

Dr. Ryan comment: If a patient has 2 medical problems such as alcohol withdrawl and pancreatitis you may want to consider a step-down admission.

Sending home first trimester pregnant patients with vaginal bleeding has risks. To mitigate risk, be sure to give very clear return instructions to the patient so that they come back right away for abdominal pain, vaginal bleeding, lightheadedness, or any other symptoms. Dr. Ryan comment: The patient going home has to understand that pain, bleeding, or lightheadedness is not expected for a normally progressing pregnancy and any of these symptoms should prompt return to the ED.

Patients with fever and encephalopathy need to be considered for LP. Consider meningitis if you don’t have another clear cut-source of infection and the patient’s mental function is significantly different from baseline.

Tyler Fluid Management in Septic Patients

Too much IV fluids is a risk for increased morbidity and mortality in sepsis patients.

50% of sepsis patients are fluid-responsive. The other 50% non-responders are further along on the Starling curve and additional fluids don’t help.

You can assess fluid responsiveness in the ED most simply by assessing for improvement of blood pressure/MAP with a 250ml fluid bolus or 3minutes of passive leg raise.

There aren’t many other ways to accurately assess volume status in septic patients. Dr. Tyler recommended that the best was the calculating the VTI at the LV outflow tract using bedside echo. Low VTI suggests that the patient could use more fluids.

IVC evaluation on bedside U/S is not useful generally unless the IVC is extreme on either side (totally collapsing or totally plethoric). You can use the IVC as a dynamic assessment of fluids status before and after fluid administration. If the IVC looks more full after a 250ml bolus you can take that as fluid responsiveness.

Ultrasound lung windows showing B lines are useful to assess for pulmonary edema.

Causes of elevated lactate: sepsis, tissue hypoxia, accelerated aerobic glycolysis (example is continuous albuterol med nebs), liver dysfunction, malignancy, medications, toxic alcohols, DKA, and thiamine deficiency.

On the other hand a normal lactate does not rule out serious problems.

Dr. Tyler is giving IV fluids to his sepsis patients who are fluid responsive in 500ml to 1 liter boluses and re-assessing prior to giving more fluids up to the 30ml/kg target.

Move to norepinephrine if you assess that patient is not improving with IV fluids.

Katiyar Billing and Coding

We are the masters of acute care and resuscitation.

Billing criteria for Critical Care: High probability of significant or life threatening deterioration. If the patient cannot be managed in an office or if you did nothing, something bad would happen, that fits the definition of critical care.

In your note, document the patient was critically ill and had risk of significant deterioration. You also need to document complex decision making and your total time involved in critical care not including procedure time. You need to document re-evaluations of the patient. It is helpful to document your interpretation of pulse ox, monitor, diagnostic testing and vital signs to support your critical care billing. It is also helpful to document that you discussed case with family and consultants.

Procedures such as intubation, arthrocentesis, lumbar puncture, and chest tubes are billed separately.

You can bill critical care for patients that you intervene on in the ED and because of your care, they no longer need ICU admission and get admitted to the floor. This would include clinical situations such as severe asthma, severe COPD exacerbation, and anaphylaxis.