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Hypertensive Emergencies in Children

(Acute Severe Hypertension)

By

Bruce A. Kaiser

, MD, Nemours/Alfred I. DuPont Hospital for Children

Last full review/revision Sep 2021| Content last modified Sep 2021
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A hypertensive emergency is severe hypertension with manifestations of damage to target organs (primarily the brain, eyes, cardiovascular system, and kidneys). Hypertensive emergencies are relatively rare in children, occurring in about 2 per 10,000 emergency department visits (1 General reference A hypertensive emergency is severe hypertension with manifestations of damage to target organs (primarily the brain, eyes, cardiovascular system, and kidneys). Hypertensive emergencies are relatively... read more ). Diagnosis is by blood pressure measurement and tests for target organ damage, including ECG, urinalysis, and serum blood urea nitrogen and creatinine measurements. Treatment is immediate blood pressure reduction, typically with IV drugs. 

In the past, severe hypertension without target organ damage was called a hypertensive urgency, and severe hypertension with end-organ dysfunction or damage was called a hypertensive emergency. The separation of these two clinical states is somewhat arbitrary because a hypertensive urgency can progress to an emergency. Today, the preferred term is "acute severe hypertension," but the terms "urgency" and "emergency" are still used in clinical practice.

The American Academy of Pediatrics' 2017 guidelines for screening and management of high blood pressure in children and adolescents suggest that physicians should be concerned about acute target organ damage in patients whose blood pressure (BP) measurement is ≥ 30 mm Hg above the 95th percentile based on age, sex, and height (see BP percentile level tables for boys Blood Pressure (BP) Percentile Levels for Boys by Age and Height (Measured and Percentile) Hypertension is sustained elevation of resting systolic blood pressure, diastolic blood pressure, or both; the pressures considered abnormal in children vary based on age up to age 13. Hypertension... read more and girls Blood Pressure (BP) Percentile Levels for Girls by Age and Height (Measured and Percentile) Hypertension is sustained elevation of resting systolic blood pressure, diastolic blood pressure, or both; the pressures considered abnormal in children vary based on age up to age 13. Hypertension... read more ). For older adolescents, the concerning BP is > 180/120. For these levels of severe hypertension, applying the term "hypertensive emergency" to children with target organ dysfunction or damage (primarily of the heart, brain, and/or kidneys) and applying the term "hypertensive urgency" to children with no symptoms and no target organ manifestations may help direct care because children with a hypertensive emergency need to be moved quickly to an emergency department or intensive care unit for evaluation, rapid testing, close monitoring, and IV treatment. Children with a hypertensive urgency also need to be quickly evaluated and treated by a physician who has experience treating children with severe hypertension, but BP does not need to be lowered as rapidly because these patients may have long-standing hypertension (which is why they do not have symptoms), and, at times, oral drugs can be used.

Importantly, children with acute secondary hypertension (particularly due to acute glomerulonephritis Acute glomerulonephritis Nephritic syndrome is defined by hematuria, variable degrees of proteinuria, usually dysmorphic red blood cells (RBCs), and often RBC casts on microscopic examination of urinary sediment. Often... read more ) can be symptomatic and even develop encephalopathy at BP levels that would be considered mild in a hypertensive adult or adolescent because, in addition to the BP level, the rate of rise is important because there is less time for the organ systems to adapt to the hypertension.

Marked BP elevation can affect several organ systems. The most common and critical are the

  • Brain: Hypertensive encephalopathy

  • Eyes: Retinal changes

  • Heart: Left ventricular heart failure

  • Kidneys: Renal insufficiency (elevated creatinine)

General reference

  • 1. Wu HP, Yang WC, Wu YK, et al: Clinical significance of blood pressure ratios in hypertensive crisis in children. Arch Dis Child 97(3):200–205, 2012. doi: 10.1136/archdischild-2011-300373

Etiology

Hypertensive emergencies are usually the result of a rapid rise in BP, which may develop in children regardless of whether they have been previously diagnosed with hypertension.

The causes of acute severe hypertension vary significantly by age:

Symptoms and Signs

In children, hypertensive emergencies manifest primarily as hypertensive encephalopathy, typically with headache, altered mental status (eg, lethargy, confusion, coma), seizures, and, in infants, irritability. These manifestations should resolve with lowering of BP.

Heart failure in hypertensive children may cause tachypnea, pulmonary edema, gallop rhythm, or a new or changed heart murmur.

Renal insufficiency is usually asymptomatic, but peripheral edema may be present.

Hypertensive retinopathy may be present, with papilledema, hemorrhages, and/or exudates.

Diagnosis

  • Blood pressure (BP) measurement

  • Testing for target organ involvement

Elevated BP should be measured using the proper technique for children Diagnosis Hypertension is sustained elevation of resting systolic blood pressure, diastolic blood pressure, or both; the pressures considered abnormal in children vary based on age up to age 13. Hypertension... read more . In a hypertensive emergency, BP measurements are usually taken with an oscillometric device, which facilitates the frequent (as often as every 2 to 3 minutes) measurements required. However, the initial measurement should be confirmed by auscultation.

Identification of conditions that would impact treatment is an immediate concern, especially an intracranial mass, uncorrected coarctation of the aorta, eclampsia, severe pain, sympathetic overactivity, or renal failure. In addition to history and physical examination findings, target organ involvement should be evaluated using tests that can be done quickly:

Hypertensive encephalopathy is a diagnosis of exclusion. Brain imaging is needed to rule out an intracranial mass or hemorrhage, which can be associated with high BP but require a different treatment approach than hypertensive encephalopathy.

Treatment

  • For hypertensive emergencies, admission to an intensive care unit (ICU) and initiation of IV antihypertensive drugs (however, if an ICU bed is not available, it is best to keep the patient in the emergency department)

  • For hypertensive urgencies, hospital admission and initiation of antihypertensive therapy

For hypertensive emergencies, the goal is to expeditiously lower BP to levels that eliminate the threats to life and stop further damage to target organs. When possible, the child should be admitted to an ICU and treated by a physician experienced in managing severe hypertension in children. However, therapy should not be delayed if admission to an ICU and/or a specialist is not readily available. In this case, the child should be managed in an emergency department by the most experienced provider available. BP should be lowered fast enough to prevent end-organ damage but slow enough not to cause hypoperfusion of these organs. Continuous IV infusion of drugs is superior, with only a 4% complication rate, as compared to 23% with the use of IV bolus drugs. When IV infusions are used, BP should be monitored every 1 to 2 minutes; if technical skill and equipment are available, an arterial line should be placed to allow continuous monitoring of BP. However, therapy should not be delayed and monitoring BP using oscillometric or auscultatory methods is acceptable. A safe rate of lowering BP is to have the systolic BP decrease by 25% every 6 hours until the symptoms resolve. Then treatment can proceed more slowly until BP is ≤ the 95th percentile (or < 140/90 in children > 12 years). Importantly, previously normotensive children with acute hypertension can be treated more aggressively than children with long-standing hypertension, who are less likely to have symptoms but who are more likely to develop hypoperfusion and thus should have BP lowered more slowly.

The preferred IV drugs are labetalol and nicardipine (see Intravenous Drugs for Children With Severe Hypertension and Symptoms or Signs of Target Organ Damage Intravenous Drugs for Children With Severe Hypertension and Symptoms or Signs of Target Organ Damage A hypertensive emergency is severe hypertension with manifestations of damage to target organs (primarily the brain, eyes, cardiovascular system, and kidneys). Hypertensive emergencies are relatively... read more ). The goal is to have the BP start to decrease within 30 minutes. If it does not, the dosing should be slowly increased toward the maximum rate and, if the effect on BP is inadequate or symptoms remain, then the other drug is added. A 2nd-line drug is used if the other first-line drug is contraindicated or the combination of labetalol and nicardipine has failed at higher doses. Once BP is under control with the IV drugs, patients can be changed to oral drugs sometimes with different drugs or drug combinations especially if the etiology has been determined.

For hypertensive urgencies (asymptomatic severe hypertension with no manifestations of organ dysfunction), IV therapy is usually not required and oral drugs can be given (see table Oral Drugs for Children With Asymptomatic Severe Hypertension Oral Drugs for Children With Asymptomatic Severe Hypertension A hypertensive emergency is severe hypertension with manifestations of damage to target organs (primarily the brain, eyes, cardiovascular system, and kidneys). Hypertensive emergencies are relatively... read more ). Patients' symptoms and BP are monitored every 15 minutes to 1 hour to start and then less frequently depending on the decrease in BP and the patient remaining asymptomatic. After BP decreases and is stable, patients can be monitored every 1 to 4 hours. Therapy is adjusted to attempt to reach the 95th percentile or 130/80 over the next 24 to 72 hours. Patients are kept in the hospital until BP is stable on medications between the 95th percentile and the 95th percentile + 12 mm Hg or for older children 130-140/80-90.

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Table
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Key Points

  • Hypertensive emergencies involve target organ dysfunction caused by elevated BP.

  • Evaluate for target organ damage using ECG, urinalysis, serum electrolytes, blood urea nitrogen, creatinine, and, if neurologic symptoms are present, CT of the head.

  • Admit to intensive care unit and consult a specialist in pediatric hypertension, treat with IV therapy, but do not delay treatment if these assets are not immediately available.

  • Preferred drugs to use include labetalol and nicardipine.

  • Goal of initial therapy is to lower BP to stop end-organ damage quickly but not so fast as to cause hypoperfusion.

  • BP should be lowered by 25% every 6 hours until the 95th percentile is approached and any related symptoms of target organ dysfunction are gone.

  • Children who develop a severe hypertensive emergency on top of their chronic hypertension need a more cautious approach to lowering their BP.

More Information

The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource

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