For many years the EmergiQuiz presentations have been one of the highlights of the AAP National Conference and Exhibition Section on Emergency Medicine Program. Pediatric Emergency Medicine Fellows present challenging cases and another fellow attempts to make the diagnosis. This is followed by an educational presentation that focuses not just on the rare diagnosis, but also the general learning inherent to the case. This post highlights a recent EmergiQuiz case.

The original EmergiQuiz case was submitted by Baillie Lott from the University of Tennessee at Le Bonheur Children’s Hospital, and was entitled “Let’s Break the Tension”

Our EmergiQuiz case began with a 14-year-old male with a month of non-bloody, nonbilious vomiting and a couple day history of fatigue. While our physical exam was normal, he consistently had systolic blood pressures over 180 and diastolics over 100. There was no personal history of hypertension in this non-obese teenager but a family history of hypertension.

Could hypertension be a harbinger of a serious diagnosis? Why do the measurements seem so out of line with what we typically see? Do these measurements alone merit a more detailed workup beyond what one might do for persistent emesis?

Clearly this qualified as severe hypertension and warranted a workup. So, what work up is indicated in this situation and what are we looking for? While primary hypertension is the most common cause of hypertension in adolescents, non-obese patients still warrant a workup for secondary causes according to the 2017 pediatric HTN guidelines [1]. Overall the most common secondary cause of hypertension in the adolescent is renal disease, and you will see initial work up focuses most specifically on screening for this. Endocrine disease, autoimmune causes, medications, and elicit substances should also be considered in the adolescent [2]. So, what can we do to help our Nephrology colleagues quickly in the ED? Urinalysis (UA), basic metabolic panel (BMP), and lipid profile can be easily obtained, and renal ultrasonography should be considered if less than 6 years of age or in those with an abnormal urinalysis or renal function [1, 3]. In the obese it is recommended to obtain liver functions as well as a hemoglobin A1C. Other studies such as a urine drug screen (UDS), thyroid studies, and complete blood count (CBC) can be considered based upon history and physical.[1]It is important to note that laboratory results have been shown to have a relatively low yield in mild to moderate hypertension [3]but generally in the emergency department we are dealing with cases of severe hypertension. In the case of severe hypertension, as will be defined below, it is reasonable to throw a wider net including: CBC, BMP, thyroid studies, plasma renin activity, fractionated plasma metanephrines, UA, UDS, and consider imaging based on history and physical exam [2].

Most patients do not require a workup in the Emergency Department for hypertension, though. What if your patient’s blood pressure is not as elevated as our patient’s? Let’s break it down by severity of hypertension:

Elevated blood pressure requires a recheck in 6 months with upper and lower extremity blood pressures with possible work up and treatment after 12 months of sustained elevated blood pressures. 

Stage 1 hypertension should be followed up in 1-2 weeks, with upper and lower extremities, and then in 3 months if sustained for workup and treatment. 

Asymptomatic stage 2 hypertension should follow up in 1 week or referral to subspecialist to be seen in the next week. Workup and treatment should be initiated at that 1 week visit if hypertension is sustained. 

Patients that are symptomatic or with acute severe hypertension defined as blood pressures > 30 mm Hg over the 95thpercentile (>180/100 if >/= 13 years of age) should be referred to the ED.[1, 2]

The traditional terms of hypertensive emergency and urgency seem to be falling out of favor for a more unified term of “hypertensive crisis”. You can imagine urgency and emergency on a spectrum under hypertensive crisis ranging from asymptomatic acute severe hypertension to symptomatic hypertension with associated end-organ damage respectively. All patients under this spectrum require emergent evaluation and treatment. As children generally present with less symptoms and different symptoms than adults, what symptoms should you as a provider be on the lookout for? Children with symptomatic hypertensive crises present most often with neurological symptoms with the most common being a headache (46-55%) followed by dizziness then nausea/vomiting [2, 4]. More severe neurologic symptoms include altered mental status and seizures. Acute visual symptoms are commonly associated with posterior reversible encephalopathy syndrome (PRES) [2]. Cardiovascular manifestations of end organ injury can include chest pain/wall tenderness and signs of heart failure, whereas renal manifestations generally present as acute kidney injury, hematuria, and/or proteinuria [2].

Screening in our patient With a BP >180/100 did in fact reveal him to be in renal failure with a renal ultrasound showing bilateral hydronephrosis. A stepwise approach following the 2017 guidelines lead to the diagnosis of renal failure as the cause of our patient’s hypertension, and further workup revealed the final diagnosis. 

References

  1. Flynn, J.T., et al., Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents.Pediatrics, 2017. 140(3).
  2. Seeman, T., G. Hamdani, and M. Mitsnefes, Hypertensive crisis in children and adolescents.Pediatr Nephrol, 2018.
  3. Wiesen, J., et al., Evaluation of pediatric patients with mild-to-moderate hypertension: yield of diagnostic testing.Pediatrics, 2008. 122(5): p. e988-93.
  4. Yang, W.C., et al., First-attack pediatric hypertensive crisis presenting to the pediatric emergency department.BMC Pediatr, 2012. 12: p. 200.