Pediatric Hypertension

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  • Renovascular HTN
  • HTNive crisis from ureteral obstruction
  • Have a healthy
  • Proper cuff size, Auscultate Repeat oscillometric if over 90%le, Seated for 5 min Right arm preferred, Width 40% of arm from elbow to shoulder, 80-100% of circumference Too Small – False elvation Too Large – False lowering Calibrate cuffs twice a year
  • Who gets it? > 3 yr, and those < 3 with risk factors
  • So who’s HTN? Everyone is…so now what?
  • Headache / confusion / seizures chest pain / palpitations
  • What’s not on this list? Pheos, and endocrine causes altogether.
  • But the most common symptom is no symptoms at all…
  • Leg and Arm BPs Heart Rate Anthropometrics Neck Facies – Cushing, Turner, Elfin Eye Grounds Throat Voice Heart Kidney – mass, bruit Genitalia – ambiguous / precocious Pulses Skin – Acneiform (adenoma sebaceum too) / CALMs, aN Muscle – weakness with aldosteronism
  • 46% sensitive,
  • Angio of aw here
  • Hydronephrosis of transplant here
  • Pediatric Hypertension

    1. 1. 4 Hypertensive Kids in 45 Minutes
    2. 2. Name: Anthony Age: 6 Sex: Male Place: Allergy Clinic BP: 145/87
    3. 3. Name: Chris Age: 17 Sex: Male Place: Inpatient BP: 180/115
    4. 4. Name: Brittiney Age: 13 Sex: Female Place: Clinic BP: 125/78
    5. 5. Name: Caleb Age: 3 Sex: Male Place: Phone Call BP: 118/75
    6. 6. Caleb Anthony Brittiney Chris
    7. 7. The Fourth Task Force Report on Pediatric High Blood Pressure
    8. 8. 6 Questions <ul><li>Does the child really have high blood pressure? </li></ul><ul><li>Do I have time to ask any more questions? </li></ul><ul><li>Why does the child have high blood pressure? </li></ul><ul><li>Does the child have other risk factors? </li></ul><ul><li>What has high blood pressure already done to the child's body? </li></ul><ul><li>What should we do about it? </li></ul>
    9. 9. 6 Questions <ul><li>Does the child really have high blood pressure? </li></ul><ul><li>Do I have time to ask any more questions? </li></ul><ul><li>Why does the child have high blood pressure? </li></ul><ul><li>Does the child have other risk factors? </li></ul><ul><li>What has high blood pressure already done to the child's body? </li></ul><ul><li>What should we do about it? </li></ul>
    10. 10. Blood Pressure Measurement Technology is in the Dark Ages. Confirm all blood pressure readings before acting.
    11. 11. It’s a Pain in the A** to Detect HTN Equipment is inherently flawed, hard to find Or gives inaccurate readings if not used right.
    12. 12. It’s a Pain in the A** to Detect HTN Spurious elevations are common
    13. 13. It’s a Pain in the A** to Detect HTN Not everyone has a BP reading.
    14. 14. It’s a Pain in the A** to Detect HTN Mild Hypertension takes weeks to confirm
    15. 15. It’s a Pain in the A** to Detect HTN Norms for Pediatric BP are found in a 4-D table
    16. 16. It’s a Pain, But you Got to Do it
    17. 17. http://www.statcoder.com/growthcharts.htm
    18. 18. Normal < 90% le Pre-Hypertension 90-95% le Stage 1 Hypertension 95% to 5 mm above 99%le Stage 2 Hypertension > 5 mm above 99%le
    19. 19. Hypertension is Common Hypertension Asthma %
    20. 20. Caleb 118/75 Anthony 145/87 Brittiney 125/78 Chris 180/115 161 cm (72%le) 95% BP = 126/82 90% BP = 122/78 114 cm (75%le) 168 cm (16%le) 98 cm (64%le) 95% BP = 113/74 99% BP = 120/82 95% BP = 133/85 99% BP = 141/93 95% BP = 110/67 99% BP = 118/75
    21. 21. Recognizing or ruling out a hypertensive emergency is the 1 st order of business in any hypertension evaluation.
    22. 22. 6 Questions <ul><li>Does the child really have high blood pressure? </li></ul><ul><li>Do I have time to ask any more questions? </li></ul><ul><li>Why does the child have high blood pressure? </li></ul><ul><li>Does the child have other risk factors? </li></ul><ul><li>What has high blood pressure already done to the child's body? </li></ul><ul><li>What should we do about it? </li></ul>
    23. 23. Is this an Emergency? <ul><li>Hypertensive Emergency </li></ul><ul><li>Elevated Blood Pressure with symptoms of end-organ damage </li></ul>Hypertensive Urgency A high BP that makes you uncomfortable
    24. 24. Hypertensive Emergencies <ul><li>Drop the Blood Pressure no more than 10% </li></ul><ul><li>Use short acting IV medications </li></ul><ul><ul><li>IV Labetolol </li></ul></ul><ul><ul><li>IV Hydralazine </li></ul></ul><ul><ul><li>IV Nicardipine drip </li></ul></ul><ul><li>Start small and then escalate your dose </li></ul><ul><li>Get the patient to a PICU </li></ul>
    25. 26. Chris Chest Pain and a splitting headache Labetolol and hydralazine given on the floor – no effect. Nicardipine drip in PICU. BP 150s/80s by noon.
    26. 27. 6 Questions <ul><li>Does the child really have high blood pressure? </li></ul><ul><li>Do I have time to ask any more questions? </li></ul><ul><li>Why does the child have high blood pressure? </li></ul><ul><li>Does the child have other risk factors? </li></ul><ul><li>What has high blood pressure already done to the child's body? </li></ul><ul><li>What should we do about it? </li></ul>
    27. 28. School Age Teenager Chronic UTIs Glomerular Disease Renovascular Disease Aortic Coarctation Essential Hypertension Essential Hypertension Glomerular Disease Renovascular Disease
    28. 29. Other Causes of Pediatric Hypertension that you still think about <ul><li>Inpatients </li></ul><ul><ul><li>Increased ICP </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Iatrogenic steroid-induced </li></ul></ul><ul><li>Uncommon outpatient causes </li></ul><ul><ul><li>Endocrine causes (Cushing, Pheo) </li></ul></ul><ul><ul><li>Pre-eclampsia </li></ul></ul>
    29. 30. <ul><li>The Younger the Patient with Hypertension, </li></ul><ul><li>the More Likely you’ll find a Cause </li></ul>Rule of Thumb #1
    30. 31. The Higher the Blood Pressure, the more likely there’s a cause Rule of Thumb #2
    31. 32. Symptoms to Ask About
    32. 33. History <ul><li>UAC as a newborn </li></ul><ul><li>UTIs or febrile illnesses </li></ul><ul><li>Medications </li></ul><ul><li>Supplements </li></ul><ul><li>Family History </li></ul>
    33. 34. Physical
    34. 35. Arm & Leg BPs A B C <ul><li>What’s Normal? </li></ul><ul><li>A = B = C </li></ul><ul><li>A = B > C </li></ul><ul><li>A = B < C </li></ul><ul><li>A > B > C </li></ul><ul><li>What’s Normal? </li></ul><ul><li>A = B = C </li></ul><ul><li>A = B > C </li></ul><ul><li>A = B < C </li></ul><ul><li>A > B > C </li></ul>
    35. 36. Eye Grounds
    36. 37. Heart Findings
    37. 38. Listen for a Bruit
    38. 39. Skin CALMs of NF-1 Acanthosis Nigricans
    39. 40. Skin
    40. 41. Labs & Imaging Pre-Hypertension Lipids Fasting Glucose Echocardiogram Retinal Exam Young Stage 1 or Stage 2 Renin Catecholamines Angiogram Urine Steroids + Teenager Stage 1 RFP Urinalysis Renal Ultrasound +
    41. 42. Pre-Hypertension Lipids Fasting Glucose Echocardiogram Retinal Exam LVH on an echocardiogram is the most common end-organ manifestation in pediatric hypertension Essential hypertension almost always occurs with other risk factors
    42. 43. Teenager Stage 1 RFP Urinalysis Renal Ultrasound Quantitate any abnormal urine protein There’s no normal creatinine in pediatrics, but there is a normal GFR. Renal vessel doppler are of questionable value.
    43. 44. Young Stage 1 or Stage 2 Renin Catecholamines Angiogram Urine Steroids Plasma renin is usually uninterpretable. Elevated urine catecholamines are usually transient and not subtle. Don’t bother with MRAs or nuclear scans; the gold standard is an angiogram.
    44. 45. Caleb Category of HTN: Young Stage 1 History & Symptoms: None Physical: Normal Labs: Normal Imaging: Echo: Mild LVH U/S: Left kidney < Right Angio: Normal
    45. 47. Brittiney Category of HTN: Pre-Hypertension History & Symptoms: Snores Physical: Elevated BMI ~ 98%le Labs: Fasting BG 121 Imaging: Echo: Normal U/S: Normal
    46. 48. <ul><li>Life-style changes </li></ul><ul><ul><li>Give a TV target of 2 hours per day or less </li></ul></ul><ul><ul><li>Write a prescription for PE </li></ul></ul><ul><ul><li>DASH diet (http://www.nhlbi.nih.gov/) </li></ul></ul><ul><li>Surveillance </li></ul><ul><ul><li>Lipids, Blood Sugars, Weight, Urine Protein </li></ul></ul><ul><ul><li>Ambulatory Blood Pressure Monitor (ABPM) </li></ul></ul>
    47. 49. Ambulatory Blood Pressure Monitor
    48. 50. Anthony Category of HTN: Young Stage 2 History & Symptoms: Intermittent headaches Physical: Single Café au Lait Labs: Normal Imaging: Echo: Moderate LVH U/S: Normal Angio:
    49. 52. Chris Category of HTN: Teenager Stage 2 History & Symptoms: Transplant; On a drip Physical: Tachycardic Labs: Creatinine 1.7 Imaging: U/S:
    50. 53. Chris Hydronephrosis, Ureteral obstruction Blood pressure dramatically better (off drips) after nephrostomy
    51. 54. 6 Questions <ul><li>Does the child really have high blood pressure? </li></ul><ul><li>Do I have time to ask any more questions? </li></ul><ul><li>Why does the child have high blood pressure? </li></ul><ul><li>Does the child have other risk factors? </li></ul><ul><li>What has high blood pressure already done to the child's body? </li></ul><ul><li>What should we do about it? </li></ul>
    52. 55. 7 Classes of Anti-hypertensives <ul><li>Diuretics </li></ul><ul><li>Beta-blockers IV labetolol </li></ul><ul><li>Central Alpha-Blockers </li></ul><ul><li>Calcium Channel Blockers nicardipine drip </li></ul><ul><li>ACE Inhibitors </li></ul><ul><li>Direct Vasodilators IV hydralazine </li></ul><ul><li>Angiotensin Receptor Blockers </li></ul><ul><li>Peripheral Blockers </li></ul>
    53. 56. Take Home Points <ul><li>Report the percentile of Blood Pressure on Any BP you get </li></ul><ul><li>Recognize a hypertensive emergency </li></ul><ul><li>Refer to the 4 th Task Force Report or your local pediatric nephrologist once you recognize a high blood pressure </li></ul>

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