Chapter 17 Hypertension
1 What is considered high blood pressure or hypertension in a child?
There’s hypertension, and then there’s HYPERtension. The distinction is between significant (>95th percentile) and severe (>99th percentile) hypertension. These classifications by age and sex were established by the Task Force on Blood Pressure Control in Children, updated in 2004. In addition to these classifications, the Task Force also developed standardized definitions for hypertensive urgency and hypertensive emergency. Hypertensive urgency refers to a severely elevated blood pressure without evidence of end-organ damage. A hypertensive emergency occurs when a child’s blood pressure is severely elevated and the child shows evidence of end-organ damage.
Cronan K, Kost SI: Renal and electrolyte emergencies. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 873–919.
National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescence: The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 114:555–576, 2004.
2 If a high blood pressure is found incidentally by the triage nurse, what two questions should you ask before you get too worried?
“What size cuff did you use?” Inappropriate cuff size can give spuriously high or low blood pressure readings. They will be falsely elevated if the cuff is too small, and low if the cuff is too big. The width of the cuff bladder should be about 40% of the circumference of the arm measured at the midpoint between the shoulder and the elbow (technically, between the acromion and the olecranon). The cuff should encircle 80–100% of the circumference of the upper arm and be about two-thirds of its length.
“Will you please repeat it?” Nonpathologic elevations in blood pressure can be caused by white coats, pain, recent activity, heat, and agitation. Ideally, a child’s blood pressure should be measured after a few minutes of inactivity, as he or she sits calmly in a parent’s lap.
3 Which patients need evaluation and treatment in the emergency department (ED), and which patients can follow up with their primary physician?
Workup and treatment: Clearly, patients with hypertensive emergencies should be treated in your department, with the initial focus on ABCs and rapidly establishing IV access. Those children experiencing hypertensive urgencies (i.e., severely elevated blood pressures without evidence of end-organ damage), should be worked up, treated, and admitted for further evaluation.
Workup only: For asymptomatic patients with significantly elevated blood pressure readings, a thorough history and physical examination and some screening laboratory tests should be performed. If there are no abnormalities in this workup, the patient can be discharged with close follow-up.
Discharge without workup: Patients being seen for another problem who were incidentally found to have mildly elevated blood pressures and are asymptomatic can be discharged to the care of their primary care physician. Ideally, the doctor should record several readings in a series of visits before confirming the diagnosis of hypertension (Fig. 17-1).
Figure 17-1 Approach to the initial emergency department triage and stabilization of the hypertensive child.
From Linakis JG: Hypertension. In Fleisher GR, Ludwig S, Henretig FM [eds]: Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, with permission.
KEY POINTS: APPROACH TO THE HYPERTENSIVE CHILD
4 Name the causes of pathologic hypertension. Discuss likely causes in babies, small children, and big children.
In general, as the age of a child increases, the likelihood of finding a cause for hypertension decreases. A newborn infant with hypertension is most likely to have either a congenital renal anomaly or a vascular problem (e.g., a renal artery thrombosis or stenosis or coarctation of the aorta). Small children may present with these vascular or congenital causes but become more likely to have renal parenchymal disease such as pyelonephritis, glomerulonephritis, or reflux nephropathy. Big children and teenagers are most likely to have essential hypertension (including obesity), though may still present with parenchymal disease. The mnemonic HYPERTENSION may help you recall some of the major causes of high blood pressure:
Y = Why? Cause unknown—primary hypertension
T = Thrombosis (renal artery, particularly if umbilical catheter was used as neonate)
E = Endocrine (congenital adrenal hyperplasia, primary aldosteronism, hyperparathyroidism)
N = Neurologic (increased intracranial, Guillain-Barré syndrome, neurofibromatosis)
S = Stenosis (renal artery stenosis or coarctation of the aorta, supravalvular aortic stenosis with Williams syndrome)
I = Ingestion (cocaine, birth control, steroids, decongestants)
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