hypertensive emergencies malcolm a. lewis consultant paediatric nephrologist
TRANSCRIPT
Hypertensive Emergencies
Malcolm A. LewisConsultant Paediatric Nephrologist
Q1. Is the patient hypertensive?
• High normal or pre-hypertension 90th to 95th centile
• Stage 1 hypertension 95th centile to 99th + 5 mmHg
• Stage 2 hypertension > 99th centile + 5 mmHg
• Severe hypertension > 95th centile + 20 mmHg
Casual BP centiles - Boys
Age 95th centile 99th centile Stage 1 limit 95th + 20 mmHg
1 103 110 115 123
3 109 116 121 129
5 112 120 125 132
7 115 122 127 135
10 119 127 132 139
13 126 133 138 146
16 134 141 146 154
Casual BP centiles - Girls
Age 95th centile 99th centile Stage 1 limit 95th + 20 mmHg
1 104 111 116 124
3 107 114 119 127
5 110 117 122 130
7 113 120 125 133
10 119 126 131 139
13 124 132 137 144
16 128 135 140 148
Rule of thumb
Start to worry if systolic; Consider panic if;
Infants and very young >120 >140
5 years old >130 >150
10 years old >140 >160
15 years old >150 >170
But;
But;
And;
Q1. Is the patient hypertensive?
• High blood pressure
– Properly taken
– Repeatedly taken
– Checked manually
Or;
• High blood pressure with symptoms
Q2. Is the patient symptomatic?
Symptoms in hypertension
None Neurological Cardio-respiratory Renal Constitutional
Convulsions Cardiac failure Oliguria Lethargy
Encephalopathy Dyspnoea Oedema Failure to thrive
Cerebral haemorrhage Orthopnoea Polyuria/Polydipsia Poor growth
PRES Wheeze Epistaxis
Facial palsy Oedema
Visual loss
Hearing loss
Headache
PRES (Posterior reversible encephalopathy syndrome)
Q3. Is there an evident cause?
Causes of hypertension
Renal Endocrine Vascular Tumours Neurological Drugs
Renal scarring CAH Coarctation Wilms' Raised intracranial pressure Steroids
Renal dysplasia GRH Renal artery stenosis Phaeochromocytoma Guillain Barre syndrome Caffeine
Glomerulonephritis Cushing's Renal vein thrombosis Neuroblastoma Cocaine
Nephrotic syndrome Conn's Microangiopathy MDMA
Polycystic kidneys Alcohol
ARF or CKD
Obsructive uropathy
Approach to the patient with hypertension
Approach to the patient with hypertension
• H
• E
• A
• T
Approach to the patient with hypertension
• History
• E
• A
• T
• Duration of symptoms if any
• Previous medical history
• Family history
• Drug history
Approach to the patient with hypertension
• H
• Examination
• A
• T
• Height and Weight
• Cutaneous stigmata
• Four limb BP
• Oedema / fluid overload
• Cardiomegaly
Approach to the patient with hypertension
• H
• E
• Assessment
• T
• FBC, biochemical profile
• Urinalysis
• Renal tract US
• ECG, echo if possible
• CXR
Approach to the patient with hypertension
• H
• E
• A
• Treatment
Treatment of severe hypertension
1. Does the patient have obstructive uropathy?
– Urinary catheter
– Nephrostomy
Treatment of severe hypertension
1. Does the patient have obstructive uropathy?
2. Is the patient fluid overloaded?
– Diuretics
Treatment of severe hypertension
1. Does the patient have obstructive uropathy?
2. Is the patient fluid overloaded?
3. Is there another known cause for hypertension?
– Treat or adjust targeted therapy
Treatment of severe hypertension
1. Does the patient have obstructive uropathy?
2. Is the patient fluid overloaded?
3. Is there another known cause for hypertension?
4. If none of the above discuss and consider
antihypertensive treatment.
Treatment of severe hypertension
Treatment of severe hypertension
Symptomatic Asymptomatic
Bolus Labetolol 0.2-1.0 mg/kg Propranolol 0.25-1 mg/kg
Bolus Hydrallazine 0.1-0.5 mg/kg Atenolol 1-2 mg/kg
Oral Minoxidil 0.1-0.3 mg/kg Amlodipine 0.1-0.4 mg/kg
Oral Minoxidil 0.1-0.3 mg/kg
Captopril 0.5-1 mg/kg
DISCUSS
Treatment of severe hypertension