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:


Stage 1 Hypertension:


SBP and/or DBP between 90th and 95th%
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



Assess blood pressure trends


Current and prior data points
Assess for other secondary causes





Manual reading with auscultation
Appropriate size cuff
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



Endocrine

Parenchymal ds
Congenital anomaly



Cardiovascular




DM
Hyperaldosteronism
Cushing Syndrome
Coarctation
Renal artery stenosis
AV fistula
Psychological


Neurologic

Increased ICP
 Pain

Pharmacologic

Stress, Anxiety

Steroids
Other

White Coat common in
hospital
Management

Hypertensive Urgency

Preferentially obtain IV access


If acute, treat medically:



Oral could be used if tolerating po (Clonidine, Isradipine)
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
 Give


IV access
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: 555576.

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.