Originally published at Pediatric EM Morsels on May 17, 2013. Reposted with permission.

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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

to another concerning cause.

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 Nicardipine : FIRST LINE Tx. no negative inotropic effects. – onset ~15 min, 1/2 life = 10-15 min Labetalol : potentially worsens hyperkalemia. Has negative inotropic effects. 1/2 life 3-5 hrs. Nitroprusside: Need to keep cyanide toxicity on your radar screen! Esmolol: Useful after congenital heart disease repair. 1/2 life 10 min. 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).

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.