Adolescents who present to the emergency department with chest pain are often frightened, as are their families. Typically, however, their pain is unlikely to be due to a pathologic or abnormal cardiac condition. As the treating provider, one should immediately assess the child for signs of serious disease—including respiratory distress, poor perfusion, altered mental status, asymmetric breath sounds, wheezing or poor air movement, and unhealthy vital signs—while remembering that tachypnea, tachycardia, and diaphoresis may be caused by anxiety. Early auscultation of the chest and palpation of pulses will most often reassure both you and the patient. When in doubt, give supplemental oxygen. Assuming that this rapid assessment does not reveal urgent respiratory or circulatory problems, attempting to calm your patient and his or her family is a good next step. Inquiring about their concerns and assuring them that cardiac disease, although rare in adolescents, will be considered by evaluating the patient’s signs.

Keeping an extensive differential in mind will help you conduct a thorough evaluation. It can be helpful to recall thoracic and abdominal anatomy. Many adolescents with acute chest pain will be worried about heart disease, so start there. Coronary ischemia is rare (but possible, especially in cocaine abuse or children with anomalous coronary arteries). Consider myocarditis, pericarditis, aortic dissection or ruptured aneurysm, arrhythmias such as supraventricular tachycardias, mitral valve prolapse (which is, in some opinions, associated with chest pain), and pulmonary hypertension. Pulmonary causes may include asthma, pneumonia, pleuritis or pleural effusion (a parapneumonic effusion related to infection or other disease, such as lupus), spontaneous or posttraumatic pneumothorax, and pneumonitis from intentional or accidental inhalations. In the chest wall, consider muscle strains, fractured ribs, costochondritis (idiopathic or viral, also known as Tietze syndrome), breast pain (often due to normal breast bud development in boys or
girls, or to benign cysts in pubertal girls). Precordial catch, also known as a Texidor twinge, is a recurrent, sharp chest or side pain, usually lasting several seconds to a few minutes, and made worse by deep breathing, without an identifiable cause. It is thought to be benign, and most adolescents outgrow it. Among gastrointestinal causes, consider GERD, esophagitis, ruptured esophagus (Boerhaave syndrome, generally caused by excessive vomiting in eating disorders such as bulimia), and gas. Depression and anxiety can manifest with a chief complaint of chest pain. Approach the history and physical with these in mind.