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Pediatric chest pain is a common chief complaint in the emergency department. Not surprisingly, children with chest pain are usually brought to the emergency department by their parents out of fear of heart disease. However, chest pain in the pediatric population is generally a benign disease. In this review, we have identified musculoskeletal pain as the most prevalent etiology of chest pain in the pediatric population, accounting for 38.7-86.3% of cases, followed by pulmonary (1.8-12.8%), gastrointestinal (0.3-9.3%), psychogenic (5.1-83.6%), and cardiac chest pain (0.3-8.0%). Various diagnostic procedures are commonly used in the emergency department for cardiac chest pain, including electrocardiogram (ECG), chest radiography, cardiac troponin examination, and echocardiography. However, these examinations demonstrate limited sensitivity in identifying cardiac etiologies, with sensitivities ranging from 0 to 17.8% for ECG and 11.0 to 17.2% for chest radiography. To avoid the overuse of these diagnostic tools, a well-designed standardized algorithm for pediatric chest pain could decrease unnecessary examination without missing severe diseases.

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PURPOSE: Slipping rib syndrome (SRS) is a challenging and underdiagnosed condition. We previously demonstrated the efficacy of costal cartilage resection for SRS and now report long-term follow-up of our updated cohort. METHODS: Retrospective chart review with prospective telephone follow-up was performed for 30 previously analyzed patients and 22 new patients to elucidate risk factors for recurrence, discuss preoperative experience, current symptoms, postoperative course, and satisfaction. RESULTS: From 2006-2020, 49 patients met inclusion criteria and underwent 67 operations. Eleven underwent re-operation for recurrence, with median time of 1.6 years [1.2, 2.6]. Median age of symptom onset was 13 years [11,14] while median age at diagnosis was 15.4 years [14, 16.7]. 29/49 (59%) patients were contacted, with median follow-up of 4.5 years [2.1, 5.7]. Twenty-one patients (72%) reported complete cure, 20 (69%) reported satisfaction 10/10, with 83% rating their satisfaction >7/10. Eleven patients (38%) were offered opioids for pain control prior to surgical evaluation. Patients with recurrence had residual or fused cartilage, hypermobile bony ribs, or both, at re-excision. CONCLUSIONS: Costal cartilage resection is an effective treatment for SRS with high satisfaction rates and an appropriate consideration for patients who fail conservative management. LEVEL OF EVIDENCE: Level IV; Case series with no comparison groups.

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We present a case in which emergency medical services (EMS) intervened on a critically ill child with known giant coronary aneurysms as sequela to her severe complicated Kawasaki disease. This patient's severe shock ultimately ended in cardiac arrest and death. We discuss the keys to recognition, and critical importance to early intervention of pediatric shock in prehospital care. We also detail the cardiac ramifications of Kawasaki disease, steps for prompt identification of high risk complaints in these patients, and opportunities for treatment.

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OBJECTIVES: To determine if patients evaluated using the pediatric chest pain standardized clinical assessment and management plan (SCAMP) in cardiology clinic were later diagnosed with unrecognized cardiac pathology, and to determine if other patients with cardiac pathology not enrolled in the SCAMP would have been identified using the algorithm. STUDY DESIGN: Patients 7-21 years of age, newly diagnosed with hypertrophic or dilated cardiomyopathy, coronary anomalies, pulmonary embolus, pulmonary hypertension, pericarditis, or myocarditis were identified from the Boston Children's Hospital (BCH) cardiac database between July 1, 2010 and December 31, 2012. Patients were cross-referenced to the SCAMP database or retrospectively assessed with the SCAMP algorithm. RESULTS: Among 98 patients with cardiac pathology, 34 (35%) reported chest pain, of whom 10 were diagnosed as outpatients. None of these patients were enrolled in the SCAMP because of alternate chief complaints (n = 4) or referral to BCH for management of the new diagnosis (n = 6). Each of these patients would have had an echocardiogram recommended by retrospective application of the SCAMP algorithm. Two other patients with cardiac pathology were among the 1124 patients assessed by the SCAMP. One patient initially diagnosed with noncardiac chest pain presented 18 months later and was diagnosed with myocarditis as an inpatient. One patient seen initially in the emergency department was subsequently diagnosed with pericarditis as an outpatient. CONCLUSIONS: Patients assessed by the chest pain SCAMP at BCH were not later diagnosed with cardiac pathology that was missed at the initial encounter. Nonenrolled outpatients with cardiac pathology and chest pain would have been successfully identified with the SCAMP algorithm.

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