Acute management of Hypertensive crisis

1. MANAGEMENT OF HYERTENSIVE
CRISIS
BY :Dr.Rabia Saleem Safdar

2. Outline
• Definition of Hypertension
• Measuring BP
• Etiology of hypertension in children
• Work up for cause
• How to treat

3. 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

4. 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

5. 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

7. HYPERTENSIVE CRISIS
Acute 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
Symptomatic
Shortness of breath,
chest pain,
numbness/weaknes
s, change in
vision, back pain,
difficulty speaking
Asymptomatic; or
severe headache,
shortness
of breath,
nosebleeds, severe
anxiety
Decrease
B.P
immediatly
Decrease
B.P
soon

8. 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

9. 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

10. •Bladder width > 40% of
mid-arm circumference.
•Bladder length 80-100%
of arm circumference
A. Ideal arm circumference
B. Range of acceptable arm
circumferences
C. Bladder length
D. Midline of bladder
E. Bladder width
F. Cuff width

13. Variables Affecting the Measurement of BP
 Patient behaviour (anxiety, cooperation)
 Medications (beta-agonists, steroids)
 Observer variability (detection of Korotkoff sounds)
 Cuff size

16. Syndromes
 Williams syndrome (associated with supravalvular aortic
stenosis, midaortic syndrome, renal artery stenosis,
renal anomalies)
 Turner syndrome (associated with coarctation of the
aorta, renal anomalies, idiopathic HTN)
 Tuberous sclerosis (associated with coarctation of the
aorta, renal artery stenosis, brain tumors)
 Neurofibromatosis (associated with essential and renovascular
HTN)
 Polycystic kidney disease, both autosomal recessive and
autosomal dominant variants

17. Comorbid Conditions
Diabete mellitus
Thyroid diseases
Rheumatologiacal disease
Cushing syndrome
Systemic lupus erythmatosus

18. Simple pneumonic to start the thinking
process??????
MONSTER

19. MONSTER
MEDICATIONS
OBESITY
NEONATAL
HISTORY
SIGN/
SYMPTOMS TRENDS
IN
FAMILY
ENDO/
RENAL
Albuterol
Amphetamines
Cocaine
Ephidrene
Gentamycin
Ketoconazole
Methylphenidate
Metoclopramide
NSAIDs
Steroids
Tacrolimus
Umblical
catheterization
Neonatal
asphyxia
BPD
Renal vein
thrombosis
Caffeine
Theophylline
Obstructive
uropathy
General
Skin
Neurological
Gastrointestinal
Cardiovascular
Genitourinary
Musculoskeletal
Essential
Secondary
Hyperlipidi
mias
Renal
diseases
Diabetes
Tumors
Systemic
diseases
ENDO
Acne
Hirsuitism
Wt gain
Wt loss
Thyroid
RENAL
Abdominal mass
Bruit
Ambiguos
genitalia

24. Complications of Hypertension
Retinopathy 27%
Encephalopathy 25%
LVH 13%
Facial palsy 12%
Visual changes 9%
Hemiplegia 8%

25. Treatment
Treatment Goals
 Prevent adverse events
 Reduce BP in controlled manner
 Preserve target organ function
 Minimize complications of therapy

26. 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

27. • Treatment Risks
Rapid 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

28. Management
Look 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

29. Just Enough
How Much??????

30. 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 height
If Unsure, slower is safer

31. Which drug?

32. 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 acting
Treatment with constant infusion:
 Steadier
 Controlled
 dependable

33. 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

34. 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

35. 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

37. Sublingual nifedipine is unpredictable and should be avoided if the duration of
hypertension is unclear and there are signs of end organ damage.

38.  Treatment must be tailored to each patient, based on the
presence of specific target organ damage and underlying
comorbidities

41. When Targeted BP Acheived
gradual reduction of short-acting drugs and gradual
introduction of oral longer-acting drugs

42. General Principles of Pharmacological
Therapy 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

45.  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

46. 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