Hypertensive Emergency

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Hypertensive Emergency

  1. 1. Hypertensive EMERGENCY 5 TAKE HOME POINTS
  2. 2. 1EMERGENCY= Severe SYMPTOMATIC elevation in BP WITH evidence of end organ damage Brain (seizures, increased ICP) Kidneys (renal insufficiency) Eyes (papilledema, retinal hemorrhage, exudates) Heart (heart failure) URGENCY= Severe elevation in BP WITHOUT severe symptoms or evidence of end organ damage Definitions
  3. 3. 2 Most common type of hypertensive emergency Severe BP elevation with cerebral edema + neurological sx of lethargy and/or seizures Pathophysiology: cerebrovascular endothelium breaks down secondary to failure of cerebral autoregulation AMS/seizures occurred in 50% of 110 patients in one retrospective series*. 27% had hypertensive retinopathy and 13% had LV hypertrophy Hypertensive encephalopathy *Deal JE et al. Arch Dis Child. 1992
  4. 4. 3Etiologies Renovascular dz (thromboembolism from umbilical a. catheterization) Congenital renal anomalies Renal vein thrombosis Coarctation of aorta BPD glomerulonephritis renovascular disease endocrine disease (pheochromocytoma, neuroblastoma, excess exogenous glucocorticoids) renal parenchymal dz preeclampsia drugs (cocaine, amphetamines) Chandar J et al. Pediatr Nephrol. 2012
  5. 5. 4 Approach Confirm marked BP elevation Rapid assessment of severity of disease Exclusion of other causes of severe HTN for which rapid reduction of BP might be harmful (intracranial injury, mass lesion, coarct, drugs) Emergent antihypertensive therapy
  6. 6. 5 Management No large clinical trials evaluating management of HTN emergencies in kids Goal: lower BP promptly by no more than 25% within 8 hours of treatment For HTN emergency: bolus dose IV hydralazine or labetolol followed by nicardipine or labetolol ggt
  7. 7. 5
  8. 8. 5 Management DRUG DOSE ONSET DURATION MECH Labetolol Nicardipine Hydralazine Bolus: 0.2-1 mg/kg (max 40 mg/dose) Infusion: 0.25-3 mg/kg/hr 2-5 mins 2-5 mins 10 min alpha/beta adrenergic blocker2-6 hr 30 min-4 hr 4-6 hours Direct vasodilator 0.2-0.6 mg/kg (max 20 mg) Ca channel blocker 0.5-4 mcg/kg/min

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