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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:
          • 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

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