From the Guidelines
An electrocardiogram (ECG or EKG) is warranted for a 15-year-old girl experiencing chest pain after a fall onto her outstretched hands. For a 15-year-old girl reporting chest pain after falling onto her hands, an electrocardiogram (EKG) should be performed as part of the initial evaluation, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. This is particularly important to rule out any cardiac contusion or other heart-related issues that may have resulted from the fall.
Steps to take:
- Perform a 12-lead EKG immediately to detect any abnormalities in heart rhythm, conduction, or signs of myocardial injury
- Conduct a thorough physical examination, focusing on the chest, ribs, and cardiovascular system
- Consider additional imaging such as a chest X-ray if indicated by physical exam findings
The EKG can help detect any abnormalities in heart rhythm, conduction, or signs of myocardial injury. While chest pain in adolescents is often musculoskeletal, especially after a fall, it's crucial to rule out more serious cardiac causes. According to the 2021 guideline, a normal ECG may be associated with left circumflex or right coronary artery occlusions and posterior wall ischemia, which is often “electrically silent”; therefore, right-sided ECG leads should be considered when such lesions are suspected 1.
Justification: Blunt chest trauma, even from a fall onto outstretched hands, can potentially cause cardiac contusion or other cardiac injuries. These injuries may not be immediately apparent but can lead to serious complications if undetected. An EKG provides a quick, non-invasive way to assess cardiac function and identify any immediate concerns that require further investigation or treatment. The 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes also recommends performing a 12-lead electrocardiogram (ECG) within 10 minutes of the patient’s arrival at an emergency facility 2. However, the 2021 guideline takes precedence due to its recency and relevance to the evaluation and diagnosis of chest pain.
From the Research
Evaluation of Chest Pain in a 15-Year-Old Girl
- The patient's symptoms and history should be carefully evaluated to determine the cause of chest pain.
- According to the study 3, chest pain can have a wide range of underlying causes, and a thorough understanding of these cases is crucial for proper management.
Use of Electrocardiogram (ECG) in Diagnosis
- An ECG can be a useful diagnostic tool for evaluating chest pain, especially in patients with suspected cardiac-related causes.
- The study 4 highlights the importance of additional lead ECGs, such as posterior and right-sided precordial leads, in diagnosing acute myocardial infarction (AMI) in patients with acute chest pain.
- However, the study 5 suggests that a modified HEART score, which includes history, EKG, age, and risk factors, can be used to identify patients with very low risk of major adverse cardiac events, and that troponin testing may not be necessary in these cases.
Considerations for Pediatric Patients
- The studies provided do not specifically address the evaluation and management of chest pain in pediatric patients.
- However, the study 3 notes that chest pain is a common reason for emergency department visits, and that a thorough understanding of the underlying causes is crucial for proper management.
- The decision to perform an ECG on a 15-year-old girl with chest pain after a fall onto her outstretched hands should be based on a careful evaluation of her symptoms and history, as well as consideration of the potential risks and benefits of the test 6, 7.