Chest Pain in a Paediatric Emergency Department Clinical Assessment and Management Reality in a Third-level Portuguese Hospital

Background: Chest pain in children 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.

Objective: To evaluate chest pain management in a paediatric ED and compare different aetiologies.

Methods: Retrospective analysis of all admissions in a paediatric ED of a Portuguese third-level hospital with a chief complaint of chest pain between January-December 2018. Statistical analysis considering a significance level of 5%.

Results: 798 visits included: 53,6% female, 80,8% adolescents (mean age: 13 years old). According to the Paediatric Canadian Triage and Acuity Scale, 77,7% was prioritized as level IV: less urgent. 65,3% reported associated symptoms including dyspnoea (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: 14,7%), 52,6% chest radiographies (altered: 17,1%) and 8,9% cardiac biomarkers (altered: 12,7%). The three main causes of chest pain were: musculoskeletal (33%), idiopathic (24,4%) and psychogenic (21,6%), with 1,1% of cardiac aetiology. Less than 3% needed hospital admission and 18,9% were oriented to an outpatient consultation. 7,1% readmissions reported. When compared to other aetiologies, psychogenic chest pain presented a statistically significant association with female gender, adolescence, psychiatric antecedents, previous stressful event and normal physical examination. Of these, less than 30% were oriented to pedopsychiatry/psychology consultations.

Conclusion: 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 post discharge 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 aetiology.