Hypertensive Emergencies

Malcolm A. LewisConsultant Paediatric Nephrologist

Q1. Is the patient hypertensive?

• High normal or pre-hypertension 90th to 95th centile

• Stage 1 hypertension 95th centile to 99th + 5 mmHg

• Stage 2 hypertension > 99th centile + 5 mmHg

• Severe hypertension > 95th centile + 20 mmHg

Casual BP centiles - Boys

Age 95th centile 99th centile Stage 1 limit 95th + 20 mmHg

1 103 110 115 123

3 109 116 121 129

5 112 120 125 132

7 115 122 127 135

10 119 127 132 139

13 126 133 138 146

16 134 141 146 154

Casual BP centiles - Girls

Age 95th centile 99th centile Stage 1 limit 95th + 20 mmHg

1 104 111 116 124

3 107 114 119 127

5 110 117 122 130

7 113 120 125 133

10 119 126 131 139

13 124 132 137 144

16 128 135 140 148

Rule of thumb

Start to worry if systolic; Consider panic if;

Infants and very young >120 >140

5 years old >130 >150

10 years old >140 >160

15 years old >150 >170

But;

But;

And;

Q1. Is the patient hypertensive?

• High blood pressure

– Properly taken

– Repeatedly taken

– Checked manually

Or;

• High blood pressure with symptoms

Q2. Is the patient symptomatic?

Symptoms in hypertension

None Neurological Cardio-respiratory Renal Constitutional

Convulsions Cardiac failure Oliguria Lethargy

Encephalopathy Dyspnoea Oedema Failure to thrive

Cerebral haemorrhage Orthopnoea Polyuria/Polydipsia Poor growth

PRES Wheeze Epistaxis

Facial palsy Oedema

Visual loss

Hearing loss

Headache

PRES (Posterior reversible encephalopathy syndrome)

Q3. Is there an evident cause?

Causes of hypertension

Renal Endocrine Vascular Tumours Neurological Drugs

Renal scarring CAH Coarctation Wilms' Raised intracranial pressure Steroids

Renal dysplasia GRH Renal artery stenosis Phaeochromocytoma Guillain Barre syndrome Caffeine

Glomerulonephritis Cushing's Renal vein thrombosis Neuroblastoma Cocaine

Nephrotic syndrome Conn's Microangiopathy MDMA

Polycystic kidneys Alcohol

ARF or CKD

Obsructive uropathy

Approach to the patient with hypertension

Approach to the patient with hypertension

• H

• E

• A

• T

Approach to the patient with hypertension

• History

• E

• A

• T

• Duration of symptoms if any

• Previous medical history

• Family history

• Drug history

Approach to the patient with hypertension

• H

• Examination

• A

• T

• Height and Weight

• Cutaneous stigmata

• Four limb BP

• Oedema / fluid overload

• Cardiomegaly

Approach to the patient with hypertension

• H

• E

• Assessment

• T

• FBC, biochemical profile

• Urinalysis

• Renal tract US

• ECG, echo if possible

• CXR

Approach to the patient with hypertension

• H

• E

• A

• Treatment

Treatment of severe hypertension

1. Does the patient have obstructive uropathy?

– Urinary catheter

– Nephrostomy

Treatment of severe hypertension

1. Does the patient have obstructive uropathy?

2. Is the patient fluid overloaded?

– Diuretics

Treatment of severe hypertension

1. Does the patient have obstructive uropathy?

2. Is the patient fluid overloaded?

3. Is there another known cause for hypertension?

– Treat or adjust targeted therapy

Treatment of severe hypertension

1. Does the patient have obstructive uropathy?

2. Is the patient fluid overloaded?

3. Is there another known cause for hypertension?

4. If none of the above discuss and consider

antihypertensive treatment.

Treatment of severe hypertension

Treatment of severe hypertension

Symptomatic Asymptomatic

Bolus Labetolol 0.2-1.0 mg/kg Propranolol 0.25-1 mg/kg

Bolus Hydrallazine 0.1-0.5 mg/kg Atenolol 1-2 mg/kg

Oral Minoxidil 0.1-0.3 mg/kg Amlodipine 0.1-0.4 mg/kg

Oral Minoxidil 0.1-0.3 mg/kg

Captopril 0.5-1 mg/kg

DISCUSS

Treatment of severe hypertension