Hypertension

National Pediatric Nighttime Curriculum

Written by: H. Barrett Fromme, MD, MHPE

The University of Chicago

Case 1

You are the intern and are paged at 8pm:“FYI: The patient in Room 678 has a BP of 125/82.–

Nurse Mike”

Signout:

11yo male here for asthma exacerbation.

Meds: Albuterol q3h, Prednisone 60mg

What Else Do You Want To Know?

Case 2 “The 8mo in room 502 is having blood pressures as

high as 113/62. Can I get your opinion? – J. Intern”

Signout: 8mo female ex 26wk premie admitted for labial abscess Wt: 6.4kg, Length 64cm

As you walk to the patient’s room, what is your differential? What questions do you have for the nurse? When would you be concerned enough to intervene?

Objectives

Describe the initial steps in evaluation of inpatient hypertension

Identify scenarios when medical therapy is warranted for inpatient hypertension

Select pharmacologic therapy for hypertensive urgency and emergency

On Call Hypertension Primer

Hypertension Definitions*

Prehypertension: SBP and/or DBP between 90th and 95th%

Stage 1 Hypertension: SBP and/or DBP ≥ 95th%, but ≤ 99th% + 5mm

Stage 2 Hypertension: SBP and/or DBP > 99th% + 5mm

*All based on gender, height and age (see references)

More Definitions Hypertensive Urgency:

Severe elevation (Stage 2) without end-organ damage

Hypertensive Emergency Severe elevation (Stage 2) with any signs of end-organ damage

End Organ Damage signs, symptoms includes: CNS (headache, seizure, lethargy, irritability) Eyes (papilledema, visual changes) Cardiac (cough, SOB, signs of heart failure, gallop, abdominal bruit) Renal (hematuria, proteinuria)

Initial Approach

Start by seeing the patient

Confirm blood pressure Manual reading with auscultation Appropriate size cuff

Assess blood pressure trends Current and prior data points

Assess for other secondary causes Pain Drugs Increased ICP Coarctation of the aorta

Look for symptoms of end-organ damage Classify as emergency, urgency or just hypertension

Differential Diagnosis Renal

Parenchymal ds Congenital anomaly

Cardiovascular Coarctation Renal artery stenosis AV fistula

Psychological Stress, Anxiety

Endocrine DM Hyperaldosteronism Cushing Syndrome

Neurologic Increased ICP Pain

Pharmacologic Steroids

Other White Coat common in

hospital

Management

Hypertensive Urgency Preferentially obtain IV access

Oral could be used if tolerating po (Clonidine, Isradipine)

If acute, treat medically: Hydralazine 0.2mg/kg/dose IV (max 20mg/dose) Labetolol 0.2mg/kg/dose IV (max 20mg/dose)

If chronic (long-standing renal ds, etc) Consult with Nephrology Oral medications potentially

Clonidine

Management

Hypertensive Emergency Obtain IV access

Give either: Hydralazine 0.2mg/kg IV (max 20mg/dose) Labetolol 0.2mg/kg IV (max 20mg/dose)

Transfer to ICU for IV medications

On-Call Hypertension Algorithm

Flynn, JT, Tullus, K. Severe hypertension in children and adolescents: pathophysiology and

treatment. Pediatr Nephrol 2008

Big Picture

The on call job is to identify urgencies/emergencies and treat as needed

Always interpret blood pressure by age and height-based norms

Work-up can be done less acutely if patient stable

Take Home Points

Always recheck BP manually with appropriate cuff

Treat underlying causes if exist

Urgency and Emergency require treatment

End-organ symptoms = Hypertensive Emergency = ICU

References

National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004; 114: 555-576.

Constantine E, Linakis J. The assessment and management of hypertensive emergencies and urgencies in children. Pediatr Emerg Care. 2005; 21: 391-396.

Questions

1. Which of the following is the appropriate cuff sizing for measuring blood pressure?

a. A cuff whose height that is 80% the length of the upper arm

b. A cuff bladder that’s length is 80% of the arm circumference

c. A cuff width that is 50% of the arm circumference

d. A cuff bladder that is 25% the arm circumference

Questions

(B) An appropriate cuff size is based on the bladder size, which should have a length that is 80% the circumference of the arm. Cuff bladder width should be 40% of the arm circumference. An incorrect cuff size (too small) can give falsely elevated blood pressures.

Questions

2. What is the definition of Stage I Hypertension?

a. SBP/DBP >85th% but <90th% for height and age

b. SBP/DBP > 90th%, but <95th% for height and age

c. SBP/DBP >95th% but <99th% for height and age

d. SBP/DBP >99th% for height and age

Questions

C) Stage I Hypertension is a blood pressure that is >95% but <99% of the age/weight based norms. Prehypertension is between the 90th and 95th%.

Questions

3. What features separate a hypertensive urgency from an emergency?

a. Percentile of blood pressure

b. Duration of elevation

c. Signs of end organ involvement

d. A & C

e. All of the above

Questions

(C) Signs of end-organ damage are what differentiate Hypertensive Urgency from Emergency, and thus determine the need for emergency treatment. Hypertensive Urgency can be treated with oral or IV medications on the floor with individual doses. Hypertensive Emergency requires more monitored IV treatment in an ICU setting.

Questions

4. Which of the following is not potentially a sign of end organ involvement?

a. Seizure

b. Irritability

c. Vomiting

d. Respiratory distress

e. None of the above

Questions

(C) Signs of end-organ damage are seen in several systems, including CNS, Renal, Cardiac and Eyes. The most obvious include mental status changes, such as irritability in infants and children, seizures, and signs of heart failure, including respiratory distress. Vomiting is not considered a sign of end-organ damage, though it may reflect increased ICP which is a secondary cause of HTN.

Questions

5. Which of the following medications does not cause hypertension?

a. Prednisone

b. Propanolol

c. Oral contraceptives

d. Ceftriaxone

e. Cocaine

Questions

(D) Though many medications can cause hypertension, Ceftriaxone does not have the side effect. The rest of the choices are in therapeutic categories, that through a variety of mechanisms, can increase blood pressure.

Questions

6. Which of the following hypertensive scenarios requires immediate treatment?

a. A 3yo with h/o renal disease and Stage I HTN, now with SBP > 99th%

b. A 2mo admitted for labial abscess with SBP > 99th% and tachycardia

c. A 10yo admitted for asthma with SBP at 98th% with tachypnea

d. A 1yo admitted for bronchiolitis with SBP > 99th% with lethargy

Questions(D) The most likely of these to need immediate

treatment is the bronchiolitic who has a Hypertensive Emergency -- the elevation of the BP combined with the end-organ symptom of lethargy is highly concerning, especially in a setting of few other causes. Though (B) could be considered a Hypertensive Urgency, the blood pressure is likely increased by the pain associated with the abscess, and therefore pain medications could be tried first. The asthmatic only has Stage I Hypertension, which is most likely influenced by the steroid treatment of asthma, and his tachypnea is likely due to the asthma. Finally, the patient with a h/o HTN and renal failure would be considered a chronic patient, and though oral medications could be used, a conversation with the nephrologist should be had.