1. Hypertensive emergencies involve severe, symptomatic elevation in blood pressure that causes end organ damage to organs like the brain, kidneys, eyes, and heart. Hypertensive urgencies involve severe elevation in blood pressure without symptoms or end organ damage. 2. Hypertensive encephalopathy is the most common hypertensive emergency and involves severe blood pressure elevation that causes cerebral edema and neurological symptoms like lethargy and seizures. 3. Etiologies of hypertensive emergencies in children include renovascular diseases, congenital renal anomalies, preeclampsia, drugs like cocaine and amphetamines, and endocrine diseases.

1. Hypertensive EMERGENCY
5 TAKE HOME POINTS

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. 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. 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. 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. 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. 5

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