What is the appropriate management for a 17-year-old experiencing chest pain, shortness of breath, and dizziness?

Management of Chest Pain, Shortness of Breath, and Dizziness in a 17-Year-Old

This 17-year-old requires immediate emergency department evaluation via EMS transport, not self-transport, because these symptoms can represent life-threatening conditions including acute coronary syndrome, pulmonary embolism, pneumothorax, or cardiac arrhythmias that require urgent diagnosis and treatment. 1, 2

Immediate Actions Required

Transport urgently by emergency medical services (EMS) to the emergency department rather than allowing self-transport, as approximately 1 in 300 chest pain patients transported by private vehicle experiences cardiac arrest en route. 1, 2

During transport or immediately upon arrival:

• Administer aspirin 250-500 mg (chewable or water-soluble) if no contraindications exist (no allergy or recent bleeding). 3, 1, 2
• Place on continuous cardiac monitoring with emergency resuscitation equipment and defibrillator readily available. 1, 2
• Obtain 12-lead ECG within 10 minutes of arrival to identify ST-segment elevation, ST-depression, T-wave inversions, new left bundle branch block, or arrhythmias. 1, 2
• Measure cardiac troponin as soon as possible after presentation. 1, 2
• Establish IV access and draw blood for complete blood count, basic chemistry, and D-dimer. 2
• Provide supplemental oxygen if oxygen saturation is <94%. 2

Critical Differential Diagnoses in Adolescents

While cardiac causes are less common in this age group, several life-threatening conditions must be excluded immediately 4:

High-Priority Life-Threatening Causes

Cardiac arrhythmias (most common cardiac cause in adolescents, accounting for 65% of cardiac chest pain cases): Look for palpitations, syncope, or family history of sudden cardiac death. 4

Pneumothorax/pneumomediastinum (air-leak syndrome): Characterized by abrupt onset, continuous pain lasting 1-2 days in older adolescents. Requires careful chest X-ray examination as pneumomediastinum can be radiologically subtle. 4

Pulmonary embolism: Although rare in healthy adolescents, PE can occur with risk factors including oral contraceptive use, prolonged immobilization, or thrombophilia. The combination of chest pain, shortness of breath, and dizziness is highly concerning. 5

Acute coronary syndrome: While uncommon at age 17, congenital coronary anomalies, Kawasaki disease sequelae, or familial hypercholesterolemia can cause ACS in adolescents. 4

Congenital heart disease: Previously undiagnosed structural abnormalities may present with these symptoms during adolescence. 4

Diagnostic Evaluation Algorithm

Step 1: ECG Interpretation (Within 10 Minutes)

If ST-segment elevation or new left bundle branch block is present: Activate cardiac catheterization laboratory immediately for primary PCI. 1, 2

If arrhythmia is detected: One adolescent with atrial flutter presented with only syncope and chest pain—combined syncope should never be neglected and requires immediate cardiac workup. 4

If ST-depression, T-wave inversions, or normal ECG: Proceed to Step 2. 1

Step 2: Obtain Chest X-Ray

Evaluate specifically for:

• Pneumothorax (abrupt continuous pain in older adolescents is characteristic of air-leak syndrome) 4
• Pneumomediastinum (requires careful examination as it can be radiologically difficult to diagnose) 4
• Pneumonia or pleural effusion 2
• Widened mediastinum (aortic pathology, though rare in this age group) 2

Step 3: Laboratory Assessment

Cardiac troponin: Essential even in adolescents with suspected cardiac symptoms. 1, 2

D-dimer: Critical for pulmonary embolism evaluation. In one case, a 16-year-old athlete with normal vital signs, physical exam, chest X-ray, and ECG had bilateral pulmonary emboli detected only because D-dimer was obtained (1916 ng/mL). 5

Complete blood count and basic chemistry: To evaluate for infection, anemia, or metabolic abnormalities. 2

Step 4: Risk-Stratified Imaging

If D-dimer is elevated or clinical suspicion for PE remains high: Obtain CT pulmonary angiography. Adult PE clinical criteria (Wells score, PERC rule) are not as sensitive or specific in pediatric populations—clinician gestalt must play a major role. 5

If cardiac pathology suspected but ECG/troponin inconclusive: Perform bedside echocardiography to evaluate for structural abnormalities, pericardial effusion, or wall motion abnormalities. 3, 2

Common Pitfalls to Avoid

Do not rely on normal vital signs to exclude serious pathology: The 16-year-old with bilateral PE had completely normal vital signs including 100% oxygen saturation on room air, normal heart rate, and normal respiratory rate. 5

Do not dismiss chest pain as benign based solely on age: While 73.6% of pediatric chest pain is idiopathic, 1.2% have air-leak syndrome and 3.8% have cardiac causes requiring urgent intervention. 4

Do not discharge with normal ECG alone: Serial troponin measurements at 6-12 hours apart are necessary if initial workup is unrevealing but clinical suspicion remains. 2

Do not overlook syncope as a red flag: Combined syncope and chest pain mandates comprehensive cardiac workup including evaluation for arrhythmias. 4

Do not assume PE is too rare to consider: Oral contraceptive use alone is sufficient risk factor for PE in adolescents, and missing this diagnosis is potentially fatal. 5

Disposition Based on Findings

Immediate cardiac catheterization laboratory activation: STEMI or high-risk arrhythmias. 1, 2

Intensive care unit admission: Confirmed PE, pneumothorax requiring intervention, hemodynamic instability, or ongoing chest pain with positive troponin. 2, 6

Hospital admission for observation: Elevated troponin without ST-elevation, suspected arrhythmia requiring telemetry monitoring, or pneumomediastinum. 1, 2, 4

Discharge with close follow-up only if: Serial troponins negative at 0 and 6-12 hours, normal ECG, normal chest X-ray, normal D-dimer, no recurrent symptoms during observation period, and hemodynamically stable throughout. 1