Elsevier Logo

English

THISISCAREPLANNINGCONTENT

COORDINATED CARE ACROSS THE CONTINUUM

Learn more about our Care Planning solution, which combines the patient story, 600+ evidence-based clinical practice guidelines and standardized assessments into one patient-centered plan of care across all care settings and disciplines.

Apr.20.2021

Hypertension Acute (Pediatric ED)

Key Information

  • An appropriately-sized blood pressure cuff is required to obtain accurate readings. The cuff’s bladder length should cover 80 to 100 percent of the child’s arm circumference and width should be at least 40 percent of the mid-arm circumference.
  • Hypertension in children and adolescents is defined as systolic or diastolic blood pressure greater than or equal to the 95th percentile for their age group, sex and height on at least 3 separate readings. Elevated blood pressure is a systolic or diastolic blood pressure measurement from the 90th percentile to less than the 95th percentile for their age group, sex and height.
  • Prevention or treatment of life-threatening organ dysfunction or damage is the goal, particularly brain, eyes, kidneys and heart. It is assessment of these target organs function, rather than specific blood pressure numbers, that is key to guiding assessment and treatment.
  • Immediate evaluation and treatment is recommended for symptomatic pediatric patients with Stage 2 hypertension (blood pressure levels greater than 5 mmHg above the 99th percentile).
  • Rapid reduction of blood pressure is dangerous in children and can result in hypoperfusion of vital organs causing treatment-related complications, such as seizures, vision loss or acute kidney injury.
  • Blood pressure by auscultation is the preferred method. If an elevated blood pressure is obtained via automated device, repeat by auscultation. Consistently high right arm blood pressures should be followed by measurements in the left arm and a leg.
  • Patients with sickle cell disease frequently present with hypertension. It is important to gain adequate pain control prior to determining another cause for blood pressure elevation.

Clinical Description

  • Care of the Emergency department patient seeking treatment for acute blood pressure elevation.

Threats to Life, Limb or Function

  • acute stroke
  • altered mental status
  • heart failure
  • progressive target-organ damage, such as heart, brain, kidneys
  • seizures

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Goal: Acute Signs/Symptoms are Managed

  • Goal: Acceptable Pain Level Achieved

    Correlate Health Status

    • Correlate health status to:

      • history, comorbidity, congenital anomaly
      • age, developmental level
      • sex, gender identity
      • baseline assessment data
      • physiologic status
      • response to medication and interventions
      • psychosocial status, social determinants of health
      • barriers to accessing care and services
      • child and family/caregiver:
        • health literacy
        • cultural and spiritual preferences
      • safety risks
      • family interaction
      • plan for transition of care

    Hypertension Acute

    Associated Documentation

    • Hypertension, Acute Management

    Presentation: Infant or Young Child

    • blood pressure acutely increased
    • difficulty feeding
    • irritability
    • listless
    • symptoms may be nonspecific or absent

    Presentation: Child or Adolescent

    • blood pressure acutely increased
    • headache
    • symptoms may be nonspecific or absent
    • visual disturbance

    Associated Signs/Symptoms

    • chest pain
    • confusion
    • nausea and vomiting
    • seizure activity

    Potential Causes

    • coarctation of aorta
    • drug ingestion
    • glomerulonephritis
    • hyperthyroidism
    • increased intracranial pressure
    • polycystic kidney disease
    • post kidney transplant
    • primary hypertension
    • renal artery stenosis
    • tumor (neuroblastoma, pheochromocytoma)

    Initial Assessment

    • airway and respiratory status
    • blood pressure and pulse measurement in all extremities
    • cardiovascular status
    • fluid status
    • hemodynamic status
    • neurologic status
    • symptoms of end-organ damage (increased work of breathing, edema, signs of stroke or encephalopathy)

    History

    • allergies
    • comorbidities
    • immunization status
    • last menstrual period (females of childbearing age)
    • medications
    • family history of hypertension, diabetes, renal disease, endocrine disease
    • history of prematurity
    • history of umbilical artery catheterizations
    • onset of symptoms
    • substance use

    Laboratory Studies

    • blood glucose level
    • BUN (blood urea nitrogen)
    • CBC (complete blood count) with differential
    • serum creatinine
    • serum electrolytes
    • thyroid function studies
    • serum lipids and triglycerides
    • urinalysis

    Diagnostics

    • 12-lead ECG (electrocardiogram)
    • chest x-ray
    • echocardiogram (assess left ventricular mass and function)

    Potential Additional Testing

    • aldosterone level
    • catecholamine level (blood, urine)
    • CT (computed tomography) scan
    • pregnancy test (for females of childbearing age)
    • renal ultrasound
    • renin level
    • serum cortisol
    • thyroid function tests
    • urine toxicology screen

    Problem Intervention

    Provide Hemodynamic Support

    • Monitor cardiovascular status. Implement ECG (electrocardiographic) monitoring.
    • Observe for and address cardiac dysrhythmia.
    • Position to support perfusion.
    • Evaluate fluid status; provide fluid therapy to improve blood flow, perfusion and tissue oxygenation.
    • Consider the need for fluid restriction with pulmonary congestion.
    • Anticipate urgent intervention in the presence of hemodynamic instability.

    Problem Intervention

    Provide Respiratory Support

    • Assess and monitor airway, breathing and circulation; maintain close surveillance for deterioration.
    • Maintain open and patent airway.
    • Position to minimize the risk of aspiration, ventilation-perfusion mismatch and breathlessness.
    • Minimize oxygen consumption and demand.
    • Provide oxygen therapy judiciously; titrate to prevent hyperoxemia.
    • Implement noninvasive or invasive positive pressure ventilation to support oxygenation and ventilation, as well as relieve respiratory distress.

    Problem Intervention

    Monitor and Manage Blood Pressure

    • Treat underlying cause, if identified.
    • Verify blood pressure reading before beginning treatment. Provide continuous blood pressure monitoring.
    • Gradually lower blood pressure via pharmacologic method if evidence of target organ damage. With hypertensive emergency, clinical situation and comorbidity should be considered to establish blood pressure goal and guide careful reduction.
    • Monitor for drug-induced side effects of antihypertensive therapy, such as reflex tachycardia or rebound hypertension.

    Problem Intervention

    Promote Comfort and Manage Pain

    • Use a consistent pain assessment tool; evaluate pain and treatment response at regular intervals.
    • Involve patient and parent/caregiver in the management plan.
    • Consider pharmacologic measures, such as an analgesic or anxiolytic agent.
    • Provide nonpharmacologic strategies, such as a quiet, calm environment and relaxation techniques.
    • Evaluate risk for opioid use and dependence.

    Problem Intervention

    Initiate Consult or Referral

    • Facilitate contact or transition, such as admission to hospital, child life, pediatric intensivist, pediatric ophthalmologist, primary care physician or pediatrician.

    Education

    General Emergency Education

    Teaching Focus

    • symptom/problem overview

    • risk factors/triggers

    • self-management

    • assistive device

    • diagnostic test

    • diet modification

    • medical device/equipment use

    • medication administration

    • opioid medication management

    • orthopaedic device

    • safe medication disposal

    • smoking cessation

    • wound care

    Population-Specific Considerations

    Forensics and Legal

    • Utilize local, state/province, federal requirements and hospital policy and protocols to manage patient care involving forensics, protective services, workman’s compensation and mandatory reportable events and illness.

    Human Trafficking

    • Human trafficking victims most frequently seek healthcare services from Emergency Departments. Healthcare professionals, alert to signs of trafficking, can guide supportive care for victims.
    • Trafficked individuals may be male or female and engaged in sex work or other forced labor. High-risk signs requiring more direct questioning about exploitation include, among others, current employment in a high-risk industry, prior sexually transmitted infections, recent immigration and other vulnerable and minority populations, as well as children who are homeless, runaways or in foster care.

    Age-Related

    • Categories of hypertension in children are calculated according to age group, sex and height (percentiles) for those under 13 years of age and those 13 years of age and older. The categories are: elevated blood pressure, Stage 1 hypertension and Stage 2 hypertension.
    • In young children, hypertension is usually due to a secondary cause that is most often of renal origin.
    • Adolescents have essential hypertension (no identifiable cause) more often than younger children.
    • There is an increase in children with hypertension related to obesity.

    References

    • American Heart Association; The American Academy of Pediatrics. (2016). Pediatric advanced life support provider manual. United States: American Heart Association. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Centers for Medicare & Medicaid Services (CMS). (2017). NQF 0495. Median Time from ED Arrival to ED Departure for Admitted ED Patients. Source[Quality Measures,Clinical Practice Guidelines]
    • Centers for Medicare & Medicaid Services (CMS). (2017). NQF 0496. Median time from ED arrival to ED departure for discharged ED patients. Source[Quality Measures,Clinical Practice Guidelines]
    • College of Respiratory Therapists of Ontario. (2013). Oxygen therapy clinical best practice guideline. Source[Quality Measures,Clinical Practice Guidelines]
    • Davis, M. D.; Walsh, B. K.; Sittig, S. E.;Restrepo, R. D.. AARC clinical practice guideline: Blood gas analysis and hemoximetry. Respiratory Care. 2013;58(10), 1694-1703. [Quality Measures,Clinical Practice Guidelines]
    • Duff, J. P.; Topjian, A. A.; Berg, M. D.; Chan, M.; Haskell, S. E.; Joyner, B. L.; Lasa, J. J.; Ley, S. J.; Raymond, T. T.; Sutton, R. M.; Hazinski, M. F.; Atkins, D. L. 2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019;140, e904-e914. doi:10.1161/CIR.0000000000000731 [Clinical Practice Guidelines]
    • Emergency Nurses Association. (2018). Emergency nursing core curriculum. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2018). Emergency nursing core curriculum. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2018). Emergency nursing core curriculum. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2018). Emergency nursing core curriculum. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2018). Emergency nursing core curriculum. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2020). Emergency Nursing Pediatric Course: Provider Manual. Burlington, MA: Emergency Nurses Association. [Expert/Committee Opinion]
    • Emergency Nurses Association. (2020). Sweet, V.; Foley, A (Eds.), Sheehy's Emergency Nursing Principles and Practice. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Flynn, J. T.; Kaelber, D. C.; Baker-Smith, C. M.; Blowey, D.; Carroll, A. E.; Daniels, S. R.; Gidding, S. S. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3), e20171904. [Quality Measures,Clinical Practice Guidelines]
    • Flynn, J. T.; Kaelber, D. C.; Baker-Smith, C. M.; Blowey, D.; Carroll, A. E.; Daniels, S. R.; Gidding, S. S. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3), e20171904. [Quality Measures,Clinical Practice Guidelines]
    • Flynn, J. T.; Kaelber, D. C.; Baker-Smith, C. M.; Blowey, D.; Carroll, A. E.; Daniels, S. R.; Gidding, S. S. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3), e20171904. [Quality Measures,Clinical Practice Guidelines]
    • Greenbaum, J.. Identifying victims of human trafficking in the emergency department. Clinical Pediatric Emergency Medicine. 2016;17(4), 241-248. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Hammond, B. B. (2013). In Sheehy's manual of emergency care. Cardiovascular emergencies. (pp.201-211). St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Harris, K. C.; Benoit, G.; Dionne, J.; Feber, J.; Cloutier, L.; Zarnke, K. B.; Padwal, R. S.; Rabi, D. M.; Fournier, A. Hypertension Canada's 2016 Canadian hypertension education program guidelines for blood pressure measurement, diagnosis, and assessment of risk of pediatric hypertension. Canadian Journal of Cardiology. 2016;32(5), 589-597. doi:http://dx.doi.org/10.1016/j.cjca.2016.02.075 [Quality Measures,Clinical Practice Guidelines]
    • Hooten, M.; Thorson, D.; Bianco, J.; Bonte, B.; Clavel Jr., A.; Hora, J.; Johnson, C.; Kirksson, E.; Noonan, M. P.; Reznikoff, C.; Schweim, K.; Wainio, J.; Walker, N.. (2016 [updated 2017, Aug]). Pain: Assessment, non-opioid treatment approaches and opioid management. (pp.160). Bloomington (MN): Institute for Clinical Systems Improvement (ICSI). Source[Quality Measures,Clinical Practice Guidelines]
    • Lopilato, A. C.; Muratagic, M.; Patel, S. Pediatric hypertension:  A pharmacological review. AACN: Advanced Critical Care. 2017;26(2), 81-90. doi:10.1097/NCI.0000000000000084 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Lopilato, A. C.; Muratagic, M.; Patel, S. Pediatric hypertension:  A pharmacological review. AACN: Advanced Critical Care. 2017;26(2), 81-90. doi:10.1097/NCI.0000000000000084 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Lurbe, E.; Agabiti-Rosei, E.; Cruickshank, J. K.; Dominiczak, A.; Erdine, S.; Hirth, A.; Invitti, C.; Litwin, M.; Mancia, G.; Pall, D.; Rascher, W.; Redon, J.; Schaefer, F.; Seeman, T.; Sinha, M.; Stabouli, S.; Webb, N. J.; Wühl, E.; Zanchetti, A. European society of hypertension guidelines for the management of high blood pressure in children and adolscents. Journal of Hypertension. 2016;34(10), 1887. doi:10.1097/HJH.0000000000001039 [Quality Measures,Clinical Practice Guidelines]
    • MacNeill, E.. Points and pearls: pediatric hypertensive emergencies; recognition and management in the emergency department. Pediatric Emergency Medicine. 2019;16(3), e1-e2. [Clinical Practice Guidelines]
    • MacNeill, E.. Points and pearls: pediatric hypertensive emergencies; recognition and management in the emergency department. Pediatric Emergency Medicine. 2019;16(3), e1-e2. [Clinical Practice Guidelines]
    • MacNeill, E.. Points and pearls: pediatric hypertensive emergencies; recognition and management in the emergency department. Pediatric Emergency Medicine. 2019;16(3), e1-e2. [Clinical Practice Guidelines]
    • Nerenberg, K. A.; Zarnke, K. B.; Leung, A. A.; Dasgupta, K.; Butalia, S.; McBrien, K.; Lamarre-Cliche, M. Hypertension Canada's 2018 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children. Canadian Journal of Cardiology. 2018;34(5), 506-525. [Quality Measures,Clinical Practice Guidelines]
    • Rabi, D. M.; McBrien, K. A.; Sapir-Pichhadze, R.; Makhla, M.; Ahmed, S. B.; Dumanski, S. M.; et al.. Hypertension Canada's 2020 comprehensive guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children. Canadian Journal of Cardiology. 2020;36, 596-624. doi:10.1016/j.cjca.2020.02.086 [Clinical Practice Guidelines]
    • Raina, R.; Mahajan, Z.; Sharma, A.; Chakraborty, R.; Mahajan, S.; Sethi, S.K.; Kapur, G.; Kaelber, D.. Hypertensive crisis in pediatric patients: An overview Introduction. Frontiers in Pediatrics. 2020;8, 667. doi:10.3389/fped.2020.588911 [Review Articles]
    • Raina, R.; Mahajan, Z.; Sharma, A.; Chakraborty, R.; Mahajan, S.; Sethi, S.K.; Kapur, G.; Kaelber, D.. Hypertensive crisis in pediatric patients: An overview Introduction. Frontiers in Pediatrics. 2020;8, 667. doi:10.3389/fped.2020.588911 [Review Articles]
    • Raina, R.; Mahajan, Z.; Sharma, A.; Chakraborty, R.; Mahajan, S.; Sethi, S.K.; Kapur, G.; Kaelber, D.. Hypertensive crisis in pediatric patients: An overview Introduction. Frontiers in Pediatrics. 2020;8, 667. doi:10.3389/fped.2020.588911 [Review Articles]
    • Registered Nurses' Association of Ontario. (2013). Assessment and management of pain. Source[Quality Measures,Clinical Practice Guidelines]
    • Seeman, T.; Hamdani, G.; Mitsnefes, M. Hypertensive crisis in children and adolescents. Pediatric Nephrology. 2018;34(12), 2523-2537. doi:10.1007/s00467-018-4092-2 Source[Expert/Committee Opinion]
    • U. S. Department of Health and Human Services. (2017). Human trafficking webinar for health care providers: SOAR to health and wellness. Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Unger, T.; Borghi, C.; Charchar, F.; Kahn, N. A.; Poulter, N. R.; Prabhakaran, D.; et al.. 2020 International society of hypertension global hypertension practice guidelines. Hypertension. 2020;(75), 1-24. doi:10.1161/HYPERTENSIONAHA.120.15026 [Clinical Practice Guidelines]
    • Whelton, P. K.; Carey, R. M.; Aronow, W. S.; Casey, D. E.; Collins, K. J.; Dennison Himmelfarb, C.; DePalma, S. M.; Gidding, S.; Jamerson, K. A.; Jones, D. W.; MacLaughlin, E. J.; Muntner, P.; Ovbiagele, B.; Smith, S. C.; Spencer, C. C.; Stafford, R. S.; Taler, S. J.; Thomas, R. J.; Williams Sr., K. A.; Williamson, J. D.; Wright, J. T. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2017; doi:https://doi.org/10.1016/j.jacc.2017.11.006 [Quality Measures,Clinical Practice Guidelines]
    • Whelton, P. K.; Carey, R. M.; Aronow, W. S.; Casey, D. E.; Collins, K. J.; Dennison Himmelfarb, C.; DePalma, S. M.; Gidding, S.; Jamerson, K. A.; Jones, D. W.; MacLaughlin, E. J.; Muntner, P.; Ovbiagele, B.; Smith, S. C.; Spencer, C. C.; Stafford, R. S.; Taler, S. J.; Thomas, R. J.; Williams Sr., K. A.; Williamson, J. D.; Wright, J. T. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2017; doi:https://doi.org/10.1016/j.jacc.2017.11.006 [Quality Measures,Clinical Practice Guidelines]
    • World Health Organization. (2016). Paediatric emergency triage, assessment and treatment: Care of critically-ill children. Geneva: World Health Organization (WHO). [Quality Measures,Clinical Practice Guidelines]
    • Young, V. B.. Effective management of pain and anxiety for the pediatric patient in the emergency department. Critical Care Nursing Clinics. 2017;29(2), 205-216. Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]

    Disclaimer

    Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.

    ;