Every kid who comes to the Emergency Department gets vital signs. And all of us I’d wager, have, at least once, waved away an abnormally high blood pressure. “It’s just pain,” or “he was crying.” And sure, the context of when and how the blood pressure was measured matters tremendously? But what about an abnormally high BP in a child who is calm, and being seen for an unrelated complain. How should we be dealing with this measurement? This guest post from Leah Finkel and Amanda Nelson addresses these questions and more.
Hypertension (HTN) in children is often not primary HTN like in adults. The recent 2017 American Heart Association (AHA) guidelines have been supported by the American Academy of Pediatrics (AAP). With these new guidelines comes a new set of blood pressure (BP) cutoffs, particularly in adolescents 13 years and older where the AHA has adapted their cutoffs based on adult values. Below is an outline of how to handle an elevated BP in the ED, and when a practitioner in the ED should worry and pursue further work-up.
- Practitioners should review all BPs done in the ED
- If elevated, the BP should be rechecked manually with the correct cuff size. A simple table below details what threshold should indicate a need for a repeat BP by age – from the aforementioned guideline:
- The correct cuff’s bladder length should be 80%–100% of the circumference of the arm, and the width should be at least 40%.
HTN is diagnosed if a child has auscultatory-confirmed BP readings ≥95th percentile on 3 different visits. A nice AAP approved BP calculator tool is found on MDCalc to help practitioners delineate the stage of hypertension. If you have an asymptomatic patient it is appropriate to discuss the measurement with the patient and family, and the primary care doctor if possible, and to arrange for near term workup in the outpatient setting.
When hypertension isn’t primary some factors to consider
#1: Blood pressure in children can be falsely elevated in the setting of pain, crying, anxiety and agitation
#2: There are multiple causes of secondary HTN including cardiac, endocrinopathies, renal and drugs
#3 Children and adolescents ≥6 years of age do not require an extensive evaluation for secondary causes of HTN if they have a family history of HTN, are overweight or obese, and/or do not have history or physical suggestive of a secondary cause of HTN.
Work-Up & Management
Work-up should be initiated in those with suspected secondary HTN or those with primary HTN that have not improved with lifestyle modifications. Typically, most work-up can be done in the outpatient clinical setting unless a patient is presenting in the ED with red flag symptoms.
Initial work-up can include renal function labs, urinalysis and 4-limb blood pressure. Consider further imaging with EKG, ECHO or renal ultrasound if any of these are abnormal.
When to Worry: Acute Severe HTN
Acute severe HTN should be considered when:
- Patient has symptoms + Stage 2 HTN
- Patient has evidence of encephalopathy, seizure, CHF or other end organ damage and BP is >30 mm Hg above the 95th percentile for children less than 13 years of age or >180/120 in an adolescent
- Work-up including complete metabolic panel, urinalysis, EKG and ECHO, and urine drug/pregnancy if applicable should be performed.
- One should also consider immediate head imaging if have neurological symptoms to look for causes of increased intracranial pressure.
- Goal of treatment is to lower BP no more than 25% of the difference between current systolic BP and the systolic BP goal.
Treatment options for severe HTN in the Pediatric Emergency Department
Contraindications: Asthma, chronic lung disease, broncho-pulmonary dysplasia, congestive heart failure, diabetes IV bolus
- IV bolus dose: 0.2 mg/kg (max 20 mg)
- Preparation: Do not dilute (give as 5 mg/mL concentration)
- Administration: IV push per local protocols
- Frequency: May need every 5 – 10 minutes
- Continuous Infusion Starting at 0.5mg/kg/hr
Alternative to labetalol for bolus dosing only
- IV bolus dose: 0.1 mg/kg (max 20 mg)
- Preparation: Do not dilute (may give 20 mg/mL concentration)
- Administration: over 1-2 minutes, do not exceed 0.2 mg/kg/min
- Frequency: May repeat in 2 hours
Alternative to labetalol for continuous administration. May cause increase in intracranial pressure.
- Continuous Infusion dose: 1 mcg/kg/min (max of 5 mg/hr)
- Peripheral IV: 0.1 mg/mL in D5W
- Central line only: 1 mg/mL in D5W
Flynn JT, Kaelber DC, Baker-Smith CM, et al.; Subcommittee on Screening and Management of High Blood Pressure in Children. Clinical practice guideline for screening and management of high blood pressure in children and adolescents.Pediatrics. 2017; 140:e20171904. doi: 10.1542/peds.2017-1904
New American Academy of Pediatrics Hypertension Guideline.” Hypertension, 73(1), pp. 31–32
AAP Pediatric Hypertension Guidelines, https://www.mdcalc.com/aap-pediatric-hypertension-guidelines
Simple Table to Identify Children and Adolescents Needing Further Evaluation of Blood Pressure. Pediatrics. 2009. https://pediatrics.aappublications.org/content/123/6/e972.figures-only