Rapid Rounds with HBD: Chest Pain

This post is adapted from teaching sessions and educational materials developed by Dr. Hannah Barber Doucet for pediatric and emergency medicine learners. The content has been edited for clarity and expanded into a written format for HipPEMcrates, with the goal of translating bedside teaching into a practical, on-shift reference for pediatric emergency clinicians.

Make sure you check out Rapid Rounds on Abdominal Trauma.

---

Chest pain in children and adolescents is a common presenting complaint in the pediatric emergency department. While most cases in previously well children are benign, our job as clinicians is to rapidly identify the rare but critical etiologies that can be life-threatening. Today’s case highlights how a structured approach can help differentiate more emergent etiologies from the run-of-the-mill complaints.

---

The Case:

A 17-year-old female presents to the ED with chest pain for the past three days.

Triage Vitals: HR 118 • BP 114/78 • RR 20 • O2 98% RA • Temp 99.9°F

Pause and consider: What key questions would you ask on history-taking to help point to a clear differential diagnosis and plan of care?

As you probe further, here’s what we learn:

History:

• She has had chest pain for the past 3 days, which is worse when she plays soccer. Associated with some intermittent shortness of breath. 
• She has felt warm but has not taken her temperature. 
• She took some acetaminophen a few hours ago which didn’t help much. 
• She was sick last week with a cold but hasn’t been coughing recently. 
• She has had no syncopal episodes. No trauma to the chest. All other ROS negative.
• She has no medical problems. 
• She takes OCPs. 
• There has been no recent travel. No family history of blood clots. No known family history of cardiac disease or of sudden death.

---

Physical Exam:

Cardiovascular: Tachycardic, regular rhythm, normal S1+S2, no murmurs/rubs/gallops, cap refill <2 sec

Respiratory: No increased WOB, lungs CTAB, no chest wall TTP

GI: Abdomen soft, NT/ND

Pause and consider: What is your current differential diagnosis and your do-not-miss diagnoses?

---

Do-Not-Miss Diagnoses

• Myocarditis
• Pericarditis
• Other cardiac (MI, arrhythmia, cardiomyopathy, CHF, congenital heart disease)
• PE
• Pneumothorax
• Trauma

More Common Diagnoses

• Pneumonia
• Costochondritis or other benign MSK like muscle strain or precordial catch
• GERD
• Anxiety/panic attack

---

Chest Pain Etiology Quick Reference

Etiology	Hints
Cardiac, generally	Exertional pain, syncope, dyspnea on exertion, new murmur, family history of cardiac disease or sudden death in young people
PE	OCP use, recent immobilization or surgery, tachycardia, hypoxia, extremity swelling
Pericarditis/Myocarditis	Recent viral illness
Pneumothorax	Sudden onset pain, absent breath sounds
Musculoskeletal	Reproducible chest wall tenderness
GI	Burning pain, worse when lying flat, epigastric tenderness

---

Pause and consider: Does this patient require further workup?

YES, because she has a number of “red flag” findings on history and exam.

While discussing HPI and exam with learners, highlight red flag questions to ask (flags for cardiac etiology or PE) as needed, including:

Red Flag Questions to Ask

Symptoms: Character/details of pain, worsening pain with exertion

Associated symptoms: SOB, syncope/exertional syncope, palpitations, fever, cough, trauma, physical activity, extremity swelling

PMHx: Recent illnesses, recent immobility/travel, hx of blood clots

PSHx: Recent surgery

Meds: OCPs

FHx: Heart problems for kids or young adults, unexpected sudden death, blood clot

---

For this patient, further workup should include investigations for cardiac and pulmonary etiologies of her symptoms, including: EKG, CXR, CBC, electrolytes, troponin, inflammatory markers (ESR and CRP), D-dimer; can add cardiac POCUS. Additionally, do not forget pain control for any ongoing chest pain!

Note: The majority of our previously healthy pediatric patients with chest pain have a more benign etiology, and often only need an EKG, a test of pain control, and maybe a CXR (if pneumonia or pneumothorax is suspected).

Drumroll please….the patient’s EKG reveals:

---

Final Diagnosis:

This patient’s workup ultimately aligns with the findings on her EKG, where diffuse ST elevation suggests pericarditis. 

---

Pause and Consider: Do you have a standardized method of reading a pediatric EKG?

Use a stepwise approach:

1. Rate
2. Rhythm 
3. Axis
4. Intervals
5. Segments/hypertrophy/ST changes – this last step is where different PEM folks might name the step differently or break out into different steps. Those treating adults often put “ST changes” here, which we should also look for (and more often than true ST elevation will see early repolarization/J point), but in pediatrics we also need to be looking for signs of cardiac hypertrophy and morphology of the different segments, such as P waves, QRS, and T waves. Pick a system and stick with it.

For more details, and age-based tables to help determine if that QRS is too big or not, I recommend Life in the Fast Lane:  https://litfl.com/paediatric-ecg-stepwise-approach/. I highly recommend practicing EKG skills until it feels standard to you.  There are many websites, both free and not, that offer pediatric EKG modules.

---

3 Key Takeaways:

1. Most pediatric chest pain is benign – know your red flag symptoms or exam findings to guide your workup.
2. History, exam, and a structured EKG approach are your first-line tools.
3. EKG, Cardiac POCUS and labs help identify rare but critical diagnoses like pericarditis, myocarditis, and PE.

The Deeper Dive

Oh, you want more details? Let’s dive in!

What (other) EKG changes might you see in pericarditis?

It depends a bit on the length of illness. A lack of ST elevations does not rule out pericarditis, particularly if the complaint is of a more chronic chest pain. EKG findings can progress through 4 stages, although multiple stages may be evident at once: 

Early: Widespread concave ST elevations across most leads (I, II, III, aVL, aVF, V2–V6) with reciprocal ST depression in aVR, and PR segment depressions (which can sometimes be the only finding).

Intermediate: The ST segments begin to normalize while T waves become flattened.

Intermediate: T waves invert.

Resolution: The EKG gradually returns to its baseline pattern.

What EKG changes might you see in myocarditis?

Essentially all patients with myocarditis will have abnormal EKG findings, but they are less specific findings than in pericarditis. Frustratingly, the most common finding is sinus tachycardia! Other common findings include ventricular hypertrophy, a low-voltage QRS, or inverted T waves. Other abnormalities, which may jump out at you much faster, include heart block and dysrhythmias.

What types of questions can we answer with cardiac POCUS? 

It’s not the same as an echo! Cardiac POCUS can give us a general sense of function, evaluate for effusion, check IVC size (which gives you information about hydration status, heart failure), and signs of right heart strain (such as in PE). If you are considering pericarditis, POCUS is useful for that effusion, and particularly if you have unstable vital signs to look for tamponade. 

Myocarditis is rare but requires a high index of suspicion – in what patients would you go looking for myocarditis, and what might you expect to find? 

Ill-appearing patients; also those with preceding or ongoing illness and persistent tachycardia/other cardiac findings despite appropriate interventions for other common causes of tachycardia, such as fever or dehydration. The majority of patients with myocarditis are missed initially! You may see a variety of EKG findings as above. In lab tests, you may see an elevated troponin, but not all will have it. WBC/CRP/ESR are often elevated, but of course can also be elevated in a variety of problems. Ultimately, these patients need a cardiology consult and an echo.

How might a young child or infant present with myocarditis/heart failure? 

Often not with chest pain but rather with vague symptoms – difficulty breathing, emesis, abdominal pain, poor feeding, or irritability. They may still have typical physical exam findings of heart failure, such as tachycardia, tachypnea, gallop, hepatomegaly, poor perfusion, or prolonged cap refill.

What decision rule tools are in our arsenal for the young adults with chest pain where we consider a PE? 

For those 18 and up, remember your PERC and Wells criteria. While not validated in patients under 18, they can also be helpful reminders of risk factors for our late adolescents close to 18. More recently, the PERC-Peds rule was prospectively evaluated in children ages 4–17 in the 2026 BEEPER study.

Further Resources:

PEMBlog Red Flags for Chest Pain in Children

Pediatric EM Morsels Chest Pain

Pediatric EM Morsels Pediatric EKG

LITFL Pediatric EKG Stepwise Approach

LITFL Pediatric Arrhythmias

LITFL EKG Changes in Myocarditis

LITFL EKG Changes in Pericarditis

ALiEM Pediatric Cardiac POCUS

EBMedicine Pediatric Myocarditis & Pericarditis

---