Hypertensive Crisis in Kids

HTN Crisis

I think that we’d all agree that 144/89 is not a normal blood pressure, but it is one that those of us who have the pleasure of caring for adults will look at with almost a sense of comfort – because it isn’t 70/30 or 210/120.  Unfortunately, however, this sense of reassurance cannot be had when dealing with children. Depending on the patient’s sex, age, and height, 144/89 may not only represent hypertension but may be associated with hypertensive crisis in kids!

Hypertension in Kids

  • Kids are becoming more and more like “little adults.”
    • The prevalence of hypertension in kids is increasing.
      • Likely associated with increases in obesity and metabolic syndrome.
    • Kids also now with increasing prevalence of biliary disease and kidney stones.
  • Naturally, normal blood pressure varies with the age of the patient.
    • For low blood pressures, we’ve discussed using the formula goal SBP = 90 + (2 x Age).
    • Normal blood pressure is defined as SBP and DBP < the 90th percentile for sex, age, and height.
    • Hypertension is defined as SBP and DBP > 95th percentile for sex, age, and height.
    • THERE ARE CHARTS!  Use them to determine the percentile… you can’t remember these numbers (or at least I cannot).
  • Hypertension in kids is more likely to be secondary to another concerning cause.
    • Adolescents have a higher incidence of essential hypertension, but should still have secondary causes investigated (see case of Coarctation).
    • Some important etiologies to consider:
      • Renal Pathology
        • Glomerulonephritis
        • Hemolytic Uremic Syndrome
        • Wilm’s Tumor
        • Nephrotic syndromes
        • Polycystic kidney disease
        • Renovascular disease
      • Coarctation of the Aorta
      • Neuroendocrine
        • Neuroblastoma
        • Pheochromocytoma
        • Thyroid disease
      • Collagen Vascular Disease
        • Lupus
        • Periarteritis nodosa
      • DRUGS (especially with those crafty teenagers)
        • Decongestants
        • Anabolic Steroids
        • Cocaine

Hypertensive Crisis in Kids

  • Hypertensive crisis occurs when there is accelerated hypertension in association with end-organ damage.
  • Common symptoms:
    • Headache (#1 complaint)
    • Nausea & Vomiting
    • Chest Pain / Left heart failure
    • Dizziness
    • Convulsions
    • Status Epilepticus
    • Coma
  • Initial Evaluation
    • Four Limb pulses and blood pressures
    • CXR
    • Chemistry panel
    • Urinalysis
    • Fundoscopic exam (papilledema?)
    • Abdominal bruits?
    • Draw and hold additional blood for subspecialist’s requests (ex, renin and aldoesterone levels)
  • Some Therapeutic Options
    1. Nicardipine: FIRST LINE Tx. no negative inotropic effects. – onset ~15 min, 1/2 life = 10-15 min
    2. Labetalol: potentially worsens hyperkalemia. Has negative inotropic effects. 1/2 life 3-5 hrs.
    3. Nitroprusside: Need to keep cyanide toxicity on your radar screen!
    4. Esmolol: Useful after congenital heart disease repair. 1/2 life 10 min.
    5. Fenoldopam: Safe with renal disease. Increases renal blood flow and induces natriuresis.
  • GOAL: Decrease blood pressure by no more than 25-30% of original value during first 8 hrs.

Convulsion due to HTN or HTN due to Convulsion?

  • Hypertensive crisis can provoke convulsions: Seizures can increase blood pressure.
  • How can you differentiate between the two and select the most appropriate therapies?
  • Study published in Critical Care Medicine found that a SBP or DBP of greater than 4 Standard Deviations above the average for the age is 78% predictive for the presence of hypertensive crisis. Values lower than this level had a negative predictive value of 100% (excluded hypertensive crisis).
  • The Cutoff BP = ([4 x Standard Deviation for age] + Mean BP for age); which equates to the following:
    • Girls:
      • 1 mnth – 130/97
      • 1 yr – 144/89
      • 6 yrs – 137/100
      • 12 yrs – 153/106
    • Boys
      • 1 mnth – 126/95
      • 1 yr – 143/89
      • 6 yrs – 136/98
      • 12 yrs – 149/105

 Proulx F, LaCroix J, Farrell CA, Gauthier M. Convulsions and hypertension in children: differentiating cause from effect. Critical Care Medicine. 1993; 23: 1541-1546.

Chadar J, Zilleruelo G. Hypertensive crisis in children. Pediatric Nephrology. 2012; 27: 741-751.

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

You may also like...

2 Responses

  1. November 24, 2014

    […] Kids are becoming more and more like “little adults” Are you prepared to manage Hypertensive Crisis in Kids? […]

  2. March 31, 2016

    […] hematuria associated with edema/proteinuria and/or hypertension warrants concern for renal disease, like Post-Infectious Glomerulonephritis. [Davis, […]

Leave a Reply