1. Hypertensive Emergencies
Amy Staples, MD, MPH
UNM Department of Pediatrics

2. Outline Measuring BP Definition of Hypertension
Etiology of hypertension in kids
When to treat
How to treat

3. Clinical Quiz 11 yo girl with a sinusitis, HA and BP 124/83
5 yo boy with rash, abd pain, joint pain, tea colored urine and BP 117/81
16 yo athletic boy in clinic for sports PE BP 132/84
HTN Treat
___ ___

4. Clinical Quiz 3 yo girl with NF, alert and playful; BP 125/77
2 yo girl with nephrotic syndrome admitted for albumin/lasix due to anarsca, with severe HA and seizure, BP 119/76; on admit 93/52
HTN Treat
___ ___

5. Outline Measuring BP Definition of Hypertension
Etiology of hypertension in kids
When to treat
How to treat

6. Measuring accurate BP’s
Cuff too small → high reading
Cuff too big → OK reading or no reading (usually not falsely low)
Lower extremities - Normally, BP is 10 to 20 mmHg higher in the legs than the arms
Prefer arm if at all possible
Right arm for comparison with standards

7. Cuff Size Bladder width > 40% of mid-arm circumference.
Bladder length % of arm circumference.
A. Ideal arm circumference
B. Range of acceptable arm
circumferences
C. Bladder length
D. Midline of bladder
E. Bladder width
F. Cuff width

8. Oscillometric Devices
Measure mean arterial pressure (MAP) and calculates SBP and DBP
The algorithms used are proprietary and NOT standardized
Results can vary widely and they do not always closely match BP values obtained by auscultation
These machines must be calibrated regularly

9. Manual vs. Automatic Manual is the gold standard
Oscillometric measurements preferred in infants and ICU settings ONLY
All high readings should be confirmed with a manual

10. Confirming High BP’s
Repeat BP in both arms and one leg (both not usually necessary)
Repeat 3 times to assure accurate
Dx of HTN requires elevated BP’s on 3 separate occasions

11. Disappearance of “HTN” with Repeated Measurement

12. Outline Measuring BP Definition of Hypertension
Etiology of hypertension in kids
When to treat
How to treat

13. New BP Normals
4th report on the diagnosis, evaluation and treatment of high blood pressure in children and adolescents
Correlates with the JNC 7
Uses new growth parameter data from NHANES
Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure

14. Definitions Normotensive
Average SBP and DBP <90th % for age, sex and height
Pre-hypertension
Average SBP or DBP >90th but <95th percentile (OR >120/80)
Hypertension
Average SBP and/or DBP >95th percentile for age, sex and height on 3 separate occasions
Stage 1: 95th-99th percentile + 5 mmHg
Stage 2: >99th percentile + 5 mm Hg

15. How to use the tables
Need:
Age, gender, height percentage
BP charts

16. 7 yo boy Ht 75%tile 50% 99/58 90% 113/73 95% 119/80 99% 127/88

17. BP tables for Infants
*Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children—1987.Pediatrics.1987;79:1–25(PR)

18. Urgency vs. Emergency
Urgency – severely elevated BP with no current evidence of secondary organ damage, although if left untreated, target organ injury may result imminently
→ Decrease BP Soon
Emergency – severely elevated BP with evidence of target organ injury
→ Decrease BP Immediately
Target organs – CNS, heart, kidney, eye
Constantine and Linakis, Pediatric Emergency Care, 2005

19. Severe Hypertension
“Hypertension that represents a threat to life or to the function of vital organs” OR
Severe hypertension is when your blood pressure goes up too!
Adelman, et al. Pediatric Nephrology, 2000

20. Outline Measuring BP Definition of Hypertension
Etiology of hypertension in kids
When to treat
How to treat

21. Etiology of Hypertension
Newborn
Early Childhood (Infant-6 yo)
School Age
(6-12 yo)
Adolescence
Renal vein thrombosis
Coarctation
Renal artery stenosis
Congenital renal anomalies
Renal parenchymal disease
Renovascular disease
Essential hypertension
Some debate over the actual frequency of renal disease vs. renovascular disease (which is more common in 2 middle age groups)
Some include BPD in newborns
Constantine and Linakis, Pediatric Emergency Care, 2005

22. Miscellaneous Causes Endocrine Elevated ICP/CNS disease
Hyperthyroid
Pheochromocytoma
Elevated ICP/CNS disease
Drug use (cocaine, ecstasy)
Medication (abrupt withdrawal)
Exercise
Traction
Hypovolemia

23. Overall 15-20% Essential Hypertension 80-85% Secondary Hypertension
60-80% Renal
8-10% Renovascular
2% Coarctation

24. Outline Measuring BP Definition of Hypertension
Etiology of hypertension in kids
When to treat
How to treat

25. Which hypertensive patients need immediate treatment?
Severe HTN
Malignant HTN - >30% above 95%
Moderate – Severe HTN - >99% with target organ damage
Symptomatic HTN
Target Organ Damage

26. Complications of Severe HTN
Retinopathy 27%
Encephalopathy 25%
LVH %
Facial palsy 12%
Visual changes 9%
Hemiplegia 8%
Deal, et al. Arch Dis Child, 1992

27. Clinical Signs of Malignant HTN
Eyes
Retinal hemorrhages, exudates and papilledema
Malignant Nephrosclerosis
ARF, Hematuria, Proteinuria
Hypertensive Encephalopathy
Headache, nausea, vomiting
Restlessness, confusion  seizures, coma
MRI (T2-weighted images) ;
Edema of the white matter of the parieto-occipital regions: posterior leukoencephalopathy

28. Papilledema, blurred optic disk, hemorrhages
Eyes
Papilledema, blurred optic disk, hemorrhages
Papilledema, blurred optic disk, hemorrhages

29. Hypertensive Encephalopathy
Failure of autoregulation
Shifted
baseline
Flynn, Ped Neph 2009; 24,

30. Hypertensive Encephalopathy
Headache, nausea, vomiting
Restlessness, confusion → seizures, coma
Posterior Leukoencephalopathy

31. Posterior Leukoencephalopathy
T1 weighted images – normal appearing
T2 weighted images – occipital hyperintensity
Edema of the white matter in the parieto-occipital regions

32. Outline Measuring BP Definition of Hypertension
Etiology of hypertension in kids
When to treat
How to treat

33. Severe Hypertension Treatment Goals Prevent adverse events
Reduce BP in controlled manner
Preserve target organ function
Minimize complications of therapy

34. Severe Hypertension Treatment Risks
Rapid reduction of BP can lead to complications
Risk of hypoperfusion (ischemia) secondary to autoregulation
Medication side effects may have adverse effects depending on cause of hypertension (e.g. ACEi)
Ischemic event in the kidney in RAS and ACE use

35. Depends on Acute vs. Chronic
How Much
Just Enough
Depends on Acute vs. Chronic

36. How Much If Unsure, slower is safer
Reduce by 25% of the planned reduction over 8-12 hrs
Another 25% over the next 8-12 hrs
Final 50% over the next 24 hrs
Planned reduction – goal is to the 95-99% for age and height
If Unsure, slower is safer

37. What to do 1st Monitor, Monitor, Monitor
Need cardiopulmonary monitoring
Need continual BP monitoring (frequently cycling cuff vs. arterial line)
Decide oral vs. IV
Oral OK if asymptomatic
IV necessary if acute target organ damage is present or imminent

38. Oral vs. IV IV Medication Rapid Action Titratable
Easy to adjust the dose
Requires IV access
PO Medication
Don’t need an IV
Harder to control effects
Absorption variable
Slower kinetics can make titrating more difficult

40. What to choose First Line PO IV Second Line PO IV Isradipine
Nifedipine IV
Nicardipine
Nitroprusside
Labetalol
Second Line PO
Clonidine IV
Hydralazine
Enalaprilat
Fenoldopam

41. Nifedipine – 0.1-0.25 mg/kg q 4-6 hours (10 mg tab available)
Isradipine
Ca channel blocker (Inhibit Ca++ entry into smooth muscle cells → vasodilitation)
Onset of action minutes
Side Effects: peripherial edema, flushing, nausea, headache, tachycardia
mg/kg/dose q 4-6 hrs
2.5 mg and 5 mg tab, 1mg/1ml suspension
Nifedipine – mg/kg q 4-6 hours (10 mg tab available)
Onset of action min

42. A note on Short acting Ca Channel Blockers
In adults with severe elevations in BP, Nifedipine has been associated with*:
Cerebral ischemia
Myocardial ischemia
Symptomatic hypotension
Preexisting MI, CAD, and hypovolemia predispose to these events.
In children Nifedipine / Isradapine have not been associated with cerebral or myocardial events. †
*Grossman E, JAMA 1996;276:
†Sinaiko AR, NEJM 1997;336:1675

43. Nicardipine Ca channel blocker Onset of action within minutes
Side Effects: same as isradipine
1-3 mcg/kg/min continuous infusion

44. Nitroprusside
Direct arteriolar/venous dilator (via nitric oxide donation)
Onset of action within seconds
Side Effects: cyanide/thiocyanate toxicity
0.5-1 mcg/kg/ min initially, titrate to max 10 mcg/kg/min
Must monitor cyanide levels if used for >24 hrs

45. Labetalol Mixed alpha/beta blocker Onset of action 5-10 min
Side Effects: bronchospasm, contraindicated in asthma, cardiogenic shock, pulmonary edema, or heart block
mg/kg/dose q min (max dose 20mg) can be converted into a drip

46. Enalaprilat
ACE inhibitor (prevents the vaso-constrictive and Na retaining effects of the RAS)
Onset of action 15 min, long duration of action
Side Effects: risk of decreased GFR
mg/kg/dose
Use in cases of severe renin mediated HTN

47. Hydralazine Direct arteriolar vasodilator
Side Effects: may cause Lupus-like syndrome
Can be given PO, IV, IM
mg/kg q 4-6 hr (max 20 mg/dose)

48. Case # 1 11 yo girl with a sinusitis, HA and BP 124/83 Ht 75th%
Blood Pressures
50% -105/62 95% -122/80 99% -128/87
Diagnosis
Pain, repeat when well, no treatment

49. Case # 2
5 yo boy with rash, abd pain, joint pain, tea colored urine and BP 117/81
Ht 25th%
Blood Pressures
50% - 93/52 95% - 110/71 99% - 118/79
Diagnosis
GN, treat with medication, likely Ca channel blocker

50. Case # 3 16 yo athletic boy in clinic for sports PE BP 132/84 Ht 90th%
Blood Pressures
50% - 119/67 95% - 137/86 99% - 144/94
Diagnosis
Possibly Pre HTN, need repeat measurements and TLC

51. Case # 4 3 yo girl with NF, alert and playful BP 125/77 Ht 25%
Blood Pressures
50% - 88/48 95% - 105/66 99% - 113/74
Diagnosis
NF (possible associated renal artery stenosis), Stage 2 HTN, treat with medication, renal vascular imaging

52. Case # 5
2 yo girl with nephrotic syndrome admitted for albumin/lasix due to anarsca, with severe HA and seizure BP 119/76; on admit 93/52
Ht – 75th%
Blood Pressures
50% - 89/46 95% - 107/64 99% - 114/71
Diagnosis
Acute HTN with end organ involvement, stop albumin, give lasix, consider IV therapy if sz continues

54. Flynn, Ped Neph 2009; 24,