November 8, 2024

Pediatric Presentation of Acute Onset of Neck and Chest Pain

By Med-Challenger · 1 minute read

A 15 yo presents to your ED with an acute onset of neck and chest pain approximately 4 hours prior to presentation. He states that he was helping prepare a surprise birthday for his mother by inflating balloons with a helium tank.

The chest pain is worsened with deep inspiration and radiates to his neck. His mother says his neck appears swollen, but the patient states he has been working out recently to try out for his high school’s football team.

There is no history of fever, cough, URI symptoms, vomiting. Past medical history is significant for asthma with hospitalizations when he was younger, but none in the past 5 years. He denies any drug use. On exam, he is awake, alert in mild respiratory distress.

VS: T 36.5°C HR 90 RR 38 BP 120/72 SpO2 95% on RA.

He has neck tenderness/swelling along the sternocleidomastoid muscles bilaterally but has good FROM without midline cervical tenderness. There is fair aeration bilaterally, but decreased breath sounds in all lung fields. There is no reproducible chest pain.

The following CXR is obtained:

test xray quiz sample video pic

Which should be the next step in the treatment of this patient?

Oral analgesics
Peak expiratory-flow rate measurement
Chest tube
Albuterol/ipatropium nebulized treatment

The correct answer is:

Oral analgesics.

This patient has developed a spontaneous pneumomediastinum most likely from helium inhalation.

Other etiologies include severe cough, forceful emesis, barotrauma, and foreign body aspiration. Pleuritic chest pain is the predominant symptom and can be accompanied with dyspnea and/or dysphagia.

Subcutaneous emphysema is found as crepitus over the neck or upper thorax on physical examination.

The CXR shows air tracking around and outlining mediastinal structures.

Conservative treatment with rest, observation and analgesics is appropriate as most cases self-resolve over several days.

Pneumomediastinum is commonly associated with asthma exacerbations. The patient in this vignette, was not having an active asthma exacerbation; therefore, bronchodilators or a peak expiratory-flow rate measurements are not required. A chest tube is not warranted as the CXR does not show a pneumothorax. [F&L pp. 1412-13]

This question appears in Med-Challenger Pediatric Emergency Medicine Exam Review with CME - 3rd Edition

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