Clinical Case

You are a senior resident working in the busy emergency department on an overnight shift. A 12-year-old girl is roomed with a chief complaint of “headache and nausea.” Per the ESI (Emergency Services Index), she was triaged a Level 2. On rapid chart review, you note that her BMI is well above the 99^th percentile, and she has a history of elevated triglycerides. Upon entering the room, you find the patient’s nurse at the bedside already in mid-conversation with the patient’s parent. The child has become more sleepy over the past couple of hours, and a manual BP confirmed the elevated triage reading of 190/120, which is well above the 95^th percentile for age (120/78) + 30! 

Before your blood pressure rises as well, know that this PEMBlog article is here to provide an overview of the recognition and management of hypertensive emergencies. 

Hypertension Epidemiology & Definition 

The increasing prevalence of obesity among children and adolescents has been identified as a significant contributor to the rising rates of hypertension, often accompanied by associated comorbidities.  Hypertension is categorized as follows: 

• Elevated BP: > or = 90^th percentile and < 95^th percentile (age 1-12 years old); 120-129/<80 (age 13+ years old) 

• Stage 1 hypertension: > or = 95^th percentile and < 95^th percentile + 12 mm Hg, or 130/80-139/89 (age 1-12 years old); 130-139/80-89 (age 13+ years old) 

• Stage 2 hypertension: > or = 95^th percentile + 12 mm Hg, or > or = 140/90 (age 1-12 years old); > or = 140/90 (age 13+ years old).  

Hypertensive emergency is a clinical diagnosis characterized by a sudden and severe elevation in blood pressure accompanied by signs of acute end-organ dysfunction. In pediatric patients, this condition should be considered when blood pressure exceeds the 95th percentile for age, height, and sex by more than 30 mm Hg, or reaches levels above 180/120 mm Hg in older adolescents.  However, the presence of end-organ damage is the defining feature of a hypertensive emergency, rather than the absolute blood pressure value alone.   

In the case presented, the patient’s blood pressure was significantly elevated, and she exhibited symptoms indicative of end-organ involvement, including altered mental status, headache, and nausea. These neurological manifestations suggest hypertensive encephalopathy, a form of end-organ damage.  While elevated blood pressure readings are critical data points, the presence of symptoms and signs of end-organ dysfunction are paramount in diagnosing a hypertensive emergency (Kamat 2024). 

Recognizing Hypertensive Emergencies 

The end-organ dysfunction component of this diagnosis presents as particular symptoms, physical exam findings, or laboratory and imaging results. Hypertensive encephalopathy which is the most acute subcategory of hypertensive emergency, is characterized by seizures, altered mental status, focal neurological findings, and visual changes (Kamat 2024).  

Hypertensive emergencies can result either from primary or secondary hypertension. Secondary hypertension is the more common cause of the two and is related to renal, cardiac, pulmonary, oncologic, endocrine, or autoimmune pathologies, in addition to medication side effects. Within the category of secondary hypertension, kidney disease (ie reflux nephropathy, glomerular disease, renovascular disease, obstructive uropathy, hemolytic uremic syndrome) is the leading etiology (Bertazza 2022). While elucidating the underlying cause of the hypertensive emergency is important for a patient’s ongoing care, your role in the pediatric ED is to: 1) stabilize airway, breathing, circulation; 2) minimize worsening end-organ dysfunction by acutely lowering blood pressure; and, 3) start work up to evaluate cause (Patel 2012).   

Physical Exam Pearls & Initial ED Workup 

Crucial, focused physical exam findings on initial assessment include:  

• Four extremity blood pressures and pulse checks 

• Abdominal exam to evaluate for hepatomegaly, abdominal bruit, or masses 

• Fundoscopy to assess for hemorrhage, infarct, or papilledema 

• Neurologic exam to assess for focality, mental status 

• Cardiac exam to evaluate for gallop, rate, murmur 

• Signs of fluid overload, such as crackles on lung exam or peripheral edema. 

Evaluation consists of lab studies, including CBC, CMP, BNP, troponin, UA, UDS, TSH with reflex to T4, and urine pregnancy test for individuals with a uterus. If available at your institution, urine NGAL, Neutrophil Gelatinase-Associated Lipocalin, is an excellent early marker for acute kidney injury (as this protein is released directly by the kidney). A value of > or = 50 ng/mL is considered abnormal. Additional lab testing can be completed to account for the broader differential diagnoses. This includes assessing for urine catecholamines, peripheral blood smear, complement levels, ANA, renin, and angiotensin. Imaging and other diagnostic studies can consist of chest x-ray, EKG, renal ultrasound with doppler, voiding cystourethrography, renal arteriography, echocardiogram, and MRI/MRA/CT of the brain/neck if neurologic complications are involved (Kamat 2024; Patel 2012). 

Pharmacologic Management & Disposition 

Intravenous medications, in the form of continuous drips, are the preferred method for lowering the patient’s blood pressure. The initial medications of choice include labetalol and nicardipine with the plan to decrease blood pressure by less than or equal to 25% of the initial blood pressure reading over the first eight hours of treatment. Patients with hypertensive emergency will require ICU admission for close hemodynamic monitoring and drip titration.  

• Labetalol dosing: 0.2-1 mg/kg bolus dose (maximum 40 mg/dose), then a continuous drip at 0.25-3 mg/kg/hr; onset of action is less than 5 minutes, and the duration of medication lasts between 2-6 hours.  

• Nicardipine dosing: bolus at 30 mcg/kg/bolus (maximum 2 mg/dose), then a continuous drip at 0.5-4 mcg/kg/min; onset of action is less than 5 minutes.  

The goal is to achieve blood pressures around the 90^th percentile for age, weight, and height over approximately 24 to 48 hours after the initial 8 hour time period. It is important to lower blood pressure readings slowly over an extended period of time to avoid possible hypoperfusion injury in patients with hypertensive emergency (Kamat 2024; Bertazza 2022).  

Previously, sodium nitroprusside was one of the most commonly used IV agents in acutely lowering blood pressure. However, for children whose hypertensive emergencies are secondary to renal or hepatic pathology, toxic metabolites (cyanide and thiocyanate) from medication breakdown can accumulate; therefore, sodium nitroprusside is contraindicated in this population (Bertazza 2022). Additionally, hydralazine is another agent that was previously utilized in pediatric hypertensive emergencies. Due to the potent vasodilator properties and effect on the RAS system, this medication requires renal dosing  adjustment for patients with chronic kidney disease. 

The Pediatric Intensive Care Unit is the most appropriate destination for patients being treated for hypertensive emergency with continuous IV medications and frequent blood pressure monitoring. For providers in community hospital settings, it is crucial to engage pediatric nephrology or intensive care unit providers as soon as possible to guide management and facilitate transfer to other institutions.  

References: 

Bertazza Partigiani N, Spagnol R, Di Michele L, et al. Management of Hypertensive Crises in Children: A Review of the Recent Literature. Front Pediatr. 2022;10:880678. Published 2022 Apr 15. doi:10.3389/fped.2022.880678. 

Deepak M. Kamat, Kim Huynh Piburn; Hypertensive Emergencies. Quick References 2024; 10.1542/aap.ppcqr.396258. 

Patel NH, Romero SK, Kaelber DC. Evaluation and management of pediatric hypertensive crises: hypertensive urgency and hypertensive emergencies. Open Access Emerg Med. 2012 Sep 5;4:85-92. doi: 10.2147/OAEM.S32809. PMID: 27147865; PMCID: PMC4753979.