Hypertensive Emergencies in Children

Abstract

Hypertensive emergencies, though uncommon in children, are potentially life threatening. While targeting blood pressure reduction to below the 90th percentile for age, gender and height, mean arterial blood pressure should be gradually lowered by one-fourth of the planned reduction over 8-12 h, a further fourth over the next 8-12 h, and the final 50% over the 24 h after that. Frequent invasive or non-invasive blood pressure monitoring is essential, as is monitoring for sensorial alteration and loss of papillary reflexes. Few antihypertensive agents have been examined in children. Continuous intravenous infusions of short acting drugs such as nitroprusside, labetalol and nicardipine are preferred to intravenous boluses of hydralazine or diazoxide. If severe symptoms are absent, oral agents such as nifedipine, clonidine, minoxidil, hydralazine, labetalol, captopril, and prazosin may be used. Nicardipine and labetalol are particularly suited in emergencies with intracranial bleeding or ischemic stroke, while furosemide, sodium nitroprusside and nitroglycerine are useful in congestive cardiac failure. Therapy with oral antihypertensive drugs should be instituted within 6-12 h of parenteral therapy, and the latter gradually withdrawn over the next 12-48 h. Oral agents have limited application as primary therapy, except when administration of intravenous infusion is likely to be delayed. This article provides a summary of the clinical approach to evaluation and management of severe symptomatic hypertension in children.

Therapy of Acute Hypertension in Hospitalized Children and Adolescents

“…Brain MRI should be obtained if there is concern for posterior reversible encephalopathy syndrome. For more detailed discussions on the pathophysiology and evaluation of pediatric hypertensive crisis, readers are encouraged to seek these publications [3, 4, 7]. …”

“…At high doses, its β 1 selectivity is lost and β 2 receptors are activated in bronchioles and the peripheral vascular which may induce bronchoconstriction [5]. A loading dose is given at 100 to 500 µg/kg followed by infusion of 50 to 150 µg/kg/min, and it can be titrated every 10-15 minutes up to 1000 µg/kg/min [4, 5, 7]. Adverse effects include bradycardia, hypoglycemia, and potential for bronchoconstriction.…”

“…There are very limited published data on the prevalence of pediatric acute HTN in contrast to chronic HTN [7]. In one retrospective study performed in a tertiary care center, 35 of 246 children admitted to the hospital with sustained HTN had severe HTN with complications including encephalopathy and congestive heart failure [8].…”

Evaluation and management of pediatric hypertensive crises: hypertensive urgency and hypertensive emergencies

“…The term ‘hypertensive crisis’ is used to describe an acute elevation in BP that can cause rapid end-organ damage. 8 A hypertensive crisis may occur de novo or in those with previously diagnosed HTN. 1 Hypertensive crises are further separated into hypertensive urgency and hypertensive emergency.…”

“… 1 Hypertensive crises are further separated into hypertensive urgency and hypertensive emergency. 8 Hypertensive urgency is defined as elevated BP without the presence of acute target-organ damage. These patients may manifest symptoms such as headache and nausea.…”