By Scott Savage, DO, FACEP, FSCP, CCHP
Posted on June 13, 2008 – Chest pain in adults that do not look obviously toxic is always a serious concern, but the goal is relatively simple: rule out acute coronary syndrome and pulmonary embolism. Find and treat the underlying cause, which is often gastroesophageal reflux disease. But what about children? In fact, what about children who are incarcerated?
They are different. Here, decoding the vital signs in context is essential. For example, a runaway 16 y/o F with chest pain had the following vital signs: P: 94, R: 18; BP: 112/64; T: 99.2; O2 Sat: 91% upon arrival to a facility where she complained of pain about six hours into a transfer trip. The physician rightly sent her to the emergency department by ambulance. Why? Look closely at the vital signs. The Oxygen saturation is only 91% despite the patient being relatively both tachycardic and tachypneic. She was found to have a pulmonary embolism, and was successfully treated. As a refresher, Table 1 shows normal pediatric vital signs:
So, the first rule is to decode the vital signs in context, and ask if the child appears safe. Once that is completed, a history is taken to try to determine the pain pattern. The system I teach is:
OPQRSTU: Onset, Place, Quality, Radiation, Severity, Timing, and Underlying factors. It is simple, easy to remember, and gives significant information. The goal is to try to classify the pain as pleuritic, musculoskeletal, or visceral. Pleuritic is generalized, sharp, and related to respiration; musculoskeletal is focal, dull, and related to movement; and visceral is dull, generalized, and may be related to eating. Obviously, the lines are not always clear cut, but looking for visceral and pleuritic components of pain can help avoid missing a serious diagnosis.
In children who are incarcerated, there are some concerns that are not present for either adults or for children in the standard population. For example, the higher rates of substance abuse lead to concern for pneumothorax (huffers), bacterial endocarditis (IV drug abuse), and prolonged QT syndrome (psychotropic use and abuse).
So what are the serious diagnoses in incarcerated children? Here, the mnemonic P4 HIM is useful. The P4 is for pulmonary embolism, pneumonia, pneumothorax, and prolonged QT. The HIM is hypertrophic cardiomyopathy, infective endocarditis, and Marfan’s syndrome.
Here are some tips for looking for these diagnoses:
1. Pneumonia: Don’t forget to look for TB. Also, if the patient declines rapidly, consider MRSA pneumonia. When it causes pneumonia, MRSA is often an aggressive disease frequently leading to death.
2. Pneumothorax: Don’t rely on the pulse ox. The tachypnea of the patient can be subtle, but sufficient to make up for the tidal volume loss.
3. Prolonged QT: Remember, it must be corrected by heart rate, so look for the QTc. Then all you need remember is that 42 is bad for you; a QTc greater than 0.42 is worrisome. Also, remember that arrhythmias that develop due to psychotropic drug overdose generally do not respond to standard ACLS drugs.
4. Infective Endocarditis: Although a history of IV drug abuse and fever are classic, remember that 85% of patients will have a heart murmur. Make sure you listen for one in an incarcerated patient who complains of chest pain, as the history of drug abuse may not be forthcoming.
References
Marx J; Adams J; Rosen P, et al: Emergency Medicine, 6th Ed. (3 Vols). NY: Mosby, 2007
Tintinalli J; Gabor K; Stapczynski S: Emergency Medicine: A comprehensive study guide, 6th Ed. NY: McGraw-Hill, 2003
Dr. Savage is an SCP Fellow and Clinical Assistant Professor of Emergency Medicine, Wright State University School of Medicine, and former Assistant Medical Director of both the Ohio and Michigan Departments of Corrections. Readers may contact Dr. Savage at sirscottsavage@hotmail.com.
