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MANAGEMENT OF HYERTENSIVE CRISIS
BY :Dr.Rabia Saleem Safdar
Outline
• Definition of Hypertension• Measuring BP• Etiology of hypertension in children• Work up for cause• How to treat
Definition
Pediatric HTN is defined as systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) >95th percentile for sex, age, and height percentile on >3 separate occasions
Definitions
• Normal blood pressure
Systolic and diastolic blood pressure below 90th centile
• Prehypertension
Systolic or diastolic blood pressure above the 90th centile (or 120/80mmHg), but below the 95th centile
Definitions
• Stage I hypertension
Systolic or diastolic blood pressure higher than or equal to the 95thcentile, but lower than the 99th centile plus 5 mm Hg
• Stage II hypertension
Systolic or diastolic BP higher than or equal to the 99th centile plus 5 mm Hg
HYPERTENSIVE CRISISAcute elevation in BP that can cause rapid end-organ damage
HYPERTENSIVE URGENCY elevated BP without the presence of acute target-organ damage
HYPERTENSIVE EMERGENCY elevated BP with acute target-organ injury
SymptomaticShortness of breath, chest pain, numbness/weakness, change invision, back pain, difficulty speaking
Asymptomatic; or severe headache, shortnessof breath, nosebleeds, severe anxiety
Decrease B.Pimmediatly
Decrease B.Psoon
END ORGAN DAMAGE IN HYPERTENSIVE CRISIS
• Damage Heart –
CHF, MI, angina
Kidneys –
acute kidney injury, microscopic hematuria
CNS –
Encephalopathy, Intracranial hemorrhage,Grade 3-4 retinopathy
Vasculature--
Aortic dissection
Measuring accurate BP’s
• Accurate cuff Cuff too small → high reading Cuff too big → low reading• Prefer right arm arm at the level of the heart and compare with the standards• Location of cuff placed on the mid-upper arm, width of the inflatable bladder being at least 40% of the arm’s
circumference bladder length of the cuff should cover 80%–100% of the
circumference of the patient’s arm
•Bladder width > 40% of mid-arm circumference.•Bladder length 80-100% of arm circumference
A. Ideal arm circumferenceB. Range of acceptable arm circumferencesC. Bladder lengthD. Midline of bladderE. Bladder widthF. Cuff width
Variables Affecting the Measurement of BP
Patient behaviour (anxiety, cooperation)
Medications (beta-agonists, steroids)
Observer variability (detection of Korotkoff sounds)
Cuff size
Syndromes
Williams syndrome (associated with supravalvular aorticstenosis, midaortic syndrome, renal artery stenosis,renal anomalies) Turner syndrome (associated with coarctation of theaorta, renal anomalies, idiopathic HTN) Tuberous sclerosis (associated with coarctation of theaorta, renal artery stenosis, brain tumors) Neurofibromatosis (associated with essential and renovascularHTN) Polycystic kidney disease, both autosomal recessive andautosomal dominant variants
Comorbid Conditions
Diabete mellitus
Thyroid diseases
Rheumatologiacal disease
Cushing syndrome
Systemic lupus erythmatosus
Simple pneumonic to start the thinking process??????
MONSTER
MONSTER
MEDICATIONS
OBESITYNEONATAL HISTORY
SIGN/SYMPTOMS TRENDS
IN FAMILY
ENDO/RENAL
AlbuterolAmphetaminesCocaineEphidreneGentamycinKetoconazoleMethylphenidateMetoclopramideNSAIDsSteroidsTacrolimus
Umblical catheterizationNeonatal asphyxiaBPDRenal vein thrombosisCaffeineTheophyllineObstructive uropathy
GeneralSkinNeurologicalGastrointestinalCardiovascularGenitourinaryMusculoskeletal
EssentialSecondaryHyperlipidimiasRenal diseasesDiabetes TumorsSystemic diseases
ENDOAcneHirsuitismWt gain Wt lossThyroidRENALAbdominal massBruitAmbiguos genitalia
Complications of HypertensionRetinopathy 27%
Encephalopathy 25%
LVH 13%
Facial palsy 12%
Visual changes 9%
Hemiplegia 8%
Treatment
Treatment Goals
Prevent adverse events
Reduce BP in controlled manner
Preserve target organ function
Minimize complications of therapy
Treatment requirements:
High dependency care Frequent blood pressure monitoring
Neuro-observations and pupillary reactions Rule out raised ICP before treating
Patient needs at least 2 large bore iv cannulae Ensure intravenous fluid bolus can be given if BP drops acutely
Consult Nephrology/ Cardiology
• Treatment RisksRapid reduction of BP can lead to complications
Risk of hypoperfusion (ischemia) secondary to autoregulation
Medication side effects may have adverse effects depending on cause of hypertension
ManagementLook for A,B,C Admit in PICU Deteremine 95th,99th BP centiles for wt ,age & gender,plot
on graph Monitor BP half hourly Maintain iv line Send investigations for CBC,S/E,RPM Arrange for CXR and ECG Attach cardiac monitor Control fits with iv diazepam Lower down BP
Just Enough
How Much??????
How much?
• Reduce by 25% of the planned reduction over 8-12 hrs
• Another 25% over the next 8-12 hrs • Final 50% over the next 24 hrs• Planned reduction – goal is to the 95-99% for
age and heightIf Unsure, slower is safer
Which drug?
RECOMMENDATION
No absolute recommendation regarding which agent to use: Use the one you are familiar with Use the one which is available
Use the agent which is short actingTreatment with constant infusion:
Steadier Controlled dependable
Give IV
Sodium Nitroprusside Onset of action: sec to 2 min
Duration :1- 10mins Dose: 0.3– 0.5 ug per kg/min
Monitor cyanide levels CI : Coarctation of aorta
OR
Hydralazine I/v Onset of action: 5 to 20 min
Duration :2- 6 hrs Dose: 0.1– 0.2mg per kg/dose only in boluses every 4-6 hrs
Monitoring
Monitor Pupillary reponse Monitor BP half hourly Monitor pulse rate Fundoscopy for Raised ICP If volume over load then Furosemide 2-4 mg/kg Salt and water restriction Periodic neurological and cardiac assessment
If rapid fall in B.P observed,stop iv infusion and give Normal saline bolus
Sublingual nifedipine is unpredictable and should be avoided if the duration of hypertension is unclear and there are signs of end organ damage.
Treatment must be tailored to each patient, based on the presence of specific target organ damage and underlying comorbidities
When Targeted BP Acheived
gradual reduction of short-acting drugs and gradual introduction of oral longer-acting drugs
General Principles of PharmacologicalTherapy while sending home
Blood pressure is considered controlled:
when less than the 95th percentile uncomplicated hypertension when less than the 90th percentile if chronic disease or end organ damage
Medications with a longer duration of action (once or twice daily dosing) are preferred to ensure better compliance
A low dose of one drug should be started first
If unsuccessful, the dose should be increased
Dose adjustment of antihypertensive medications should not be made more frequently than every few days
Another drug can be added if response to one drug is poor at high dose
Degree of BP control
Extent of understanding of the disease and its treatment on the part of both the parents or caregivers or the child
Adherence to pharmacologic treatments
Ability to monitor BP properly at home
Likelihood of drug adverse effects
Monitor for complications of hypertension
Take Home Points• Distinguish between hypertensive emergency and urgency
• Presence of target organ damage and determine its severity
• Hypertensive emergency is managed in an intensive care unit in monitored settings with parenteral drugs
• Goal of therapy include Reduction by 25% of the planned reduction over 8-12 hrs ,another 25% over the next 8-12 hrs and final 50% over the next 24 hrs
• Specific target organ involvement and underlying patient comorbidities dictate appropriate therapy
![Chest 2007 Marik 1949 62[1]Hypertensive Crisis](https://img.pdfslide.us/doc/110x75/55254eca550346a76e8b479c/chest-2007-marik-1949-621hypertensive-crisis.jpg)
