Hypertensive EMERGENCY5 TAKE HOME POINTS

1EMERGENCY= Severe SYMPTOMATIC elevation in BP WITH evidence of end organ damage

Brain (seizures, increased ICP)Kidneys (renal insufficiency)Eyes (papilledema, retinal hemorrhage, exudates)Heart (heart failure)

URGENCY= Severe elevation in BP WITHOUT severesymptoms or evidence of end organ damage

Definitions

2Most common type of hypertensive emergency

Severe BP elevation with cerebral edema +neurological sx of lethargy and/or seizures

Pathophysiology: cerebrovascular endotheliumbreaks down secondary to failure of cerebral autoregulation

AMS/seizures occurred in 50% of 110 patientsin one retrospective series*. 27% had hypertensive retinopathy and 13% had LV hypertrophy

Hypertensive encephalopathy

*Deal JE et al. Arch Dis Child. 1992

3Etiologies

Renovascular dz(thromboembolism from

umbilical a. catheterization)

Congenital renal anomalies

Renal vein thrombosis

Coarctation of aorta

BPD

glomerulonephritis

renovascular disease

endocrine disease(pheochromocytoma,

neuroblastoma,excess exogenous

glucocorticoids)

renal parenchymal dz

preeclampsia

drugs(cocaine, amphetamines)

Chandar J et al. Pediatr Nephrol. 2012

4Approach

Confirm marked BP elevation

Rapid assessment of severity of disease

Exclusion of other causes of severe HTN for which rapid reduction of BP might be harmful

(intracranial injury, mass lesion, coarct, drugs)

Emergent antihypertensive therapy

5Management

No large clinical trials evaluating management of HTN emergencies in kids

Goal: lower BP promptly by no more than 25% within 8 hours of treatment

For HTN emergency: bolus dose IV hydralazine or labetolol followed by nicardipine or labetolol ggt

5

5Management

DRUG DOSE ONSET DURATION MECH

Labetolol

Nicardipine

Hydralazine

Bolus: 0.2-1 mg/kg (max 40 mg/dose)

Infusion: 0.25-3 mg/kg/hr

2-5 mins

2-5 mins

10 min

alpha/beta adrenergic

blocker2-6 hr

30 min-4 hr

4-6 hoursDirect

vasodilator0.2-0.6 mg/kg

(max 20 mg)

Ca channel blocker

0.5-4 mcg/kg/min