What is the appropriate protocol for pediatric cardiology triage nurses to follow when assessing chest pain in children and adolescents over the phone?

Pediatric Cardiology Triage Protocol for Chest Pain Assessment via Phone

Pediatric cardiology triage nurses should follow a structured protocol when assessing chest pain in children and adolescents over the phone, focusing on identifying potentially serious cardiac causes while appropriately reassuring families when symptoms suggest benign etiologies.

Initial Assessment

Key History Elements

• Characteristics of chest pain:
  • Location: Retrosternal vs. localized point tenderness
  • Quality: Pressure/heaviness/squeezing (more concerning) vs. sharp/stabbing (less concerning)
  • Radiation: Pain radiating to left arm, neck, jaw (more concerning)
  • Duration: Prolonged (minutes) vs. fleeting (seconds)
  • Timing: Recent onset or change in pattern vs. chronic/recurrent 1

High-Risk Features Requiring Immediate Attention

1. Exertional chest pain (occurs during or immediately after physical activity)
2. Syncope or near-syncope with chest pain
3. Family history of:
   • Sudden cardiac death
   • Premature coronary artery disease
   • Hypertrophic cardiomyopathy
4. Associated symptoms:
   • Palpitations
   • Shortness of breath
   • Diaphoresis
   • Dizziness 1, 2

Triage Decision Algorithm

RED FLAGS - Immediate Emergency Department Referral

• Chest pain with syncope or pre-syncope
• Chest pain during exertion that caused the child to stop activity
• Chest pain with palpitations and shortness of breath
• Severe, sudden-onset "ripping" chest pain (concern for aortic pathology)
• Chest pain with fever and ill appearance (concern for myocarditis/pericarditis) 1, 2

URGENT Evaluation (Same-Day Cardiology Appointment)

• Exertional chest pain without syncope
• Chest pain with concerning family history
• Chest pain with abnormal cardiac exam reported by primary care provider
• Chest pain with palpitations but no other concerning features 1, 3

NON-URGENT Evaluation (Routine Cardiology Appointment)

• Non-exertional chest pain with normal cardiac exam by primary care
• Recurrent chest pain with previous negative cardiac evaluation
• Chest pain clearly associated with respiratory infections, cough, or trauma 4, 3

PRIMARY CARE Referral (No Immediate Cardiology Needed)

• Brief, sharp, localized chest pain
• Pain reproducible with palpation or movement
• Pain clearly related to cough or deep breathing
• Pain with characteristics of costochondritis or musculoskeletal origin 3, 5

Age-Specific Considerations

Preschool Children (3-6 years)

• Obtain history primarily from parents/caregivers
• Ask about specific behaviors observed during episodes (stopping play, crying, rubbing chest)
• Determine if child can localize pain with one finger (more likely musculoskeletal) 1

School-Age Children (7-11 years)

• Allow child to describe symptoms in their own words first
• Ask about relationship to school, sports, or social stressors
• Determine if pain prevents participation in normal activities 1

Adolescents (12-18 years)

• Interview adolescent separately if possible
• Ask specifically about:
  • Substance use (caffeine, energy drinks, tobacco, illicit drugs)
  • Stress/anxiety triggers
  • Sports participation level and intensity 1

Communication Guidance

Effective Questioning Techniques

• Use open-ended questions: "Tell me about the pain"
• Avoid leading questions: "Is the pain sharp?" (instead ask "How would you describe the pain?")
• Assess impact: "What happens when you feel this pain?"
• Determine parental concern level: "On a scale of 1-10, how worried are you about this pain?" 1

Documentation Requirements

1. Duration and frequency of symptoms
2. Precipitating and alleviating factors
3. Associated symptoms
4. Previous evaluations and results
5. Family cardiac history
6. Triage decision and rationale 1

Parent Education and Reassurance

For Non-Cardiac Chest Pain

• Explain that >95% of pediatric chest pain is non-cardiac in origin
• Discuss common causes (musculoskeletal, respiratory, gastrointestinal, psychogenic)
• Provide specific return precautions for concerning symptoms
• Document education provided 4, 3

For Potentially Cardiac Chest Pain

• Explain rationale for urgent evaluation without causing excessive anxiety
• Provide clear instructions on where to go and what to expect
• Advise on activity restrictions until evaluation complete 1, 2

Common Pitfalls to Avoid

• Do not describe chest pain as "atypical" as this can be misinterpreted as benign 1
• Do not dismiss adolescent chest pain as "just anxiety" without appropriate assessment
• Do not fail to recognize that exertional chest pain requires evaluation even if brief
• Do not overlook family history of sudden cardiac death or cardiomyopathy 1, 2

By following this structured protocol, pediatric cardiology triage nurses can effectively assess chest pain complaints over the phone, appropriately triage patients based on risk, and provide reassurance when indicated while ensuring that potentially serious cardiac conditions are not missed.