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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:
- 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

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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.

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