A hypertensive emergency is a particularly severe, sudden form of high blood pressure that can damage one or more vital organs.
(See also High Blood Pressure in Children and High Blood Pressure in adults.)
Hypertensive emergencies occur when blood pressure rapidly increases.
In children, the first symptoms of a hypertensive emergency are typically a headache, listlessness, confusion, and seizures and, in infants, irritability.
Doctors diagnose hypertensive emergency by measuring blood pressure and doing tests for organ damage, such as electrocardiography, echocardiography, and blood and urine tests.
Treatment of hypertensive emergencies involves admitting children to an intensive care unit and giving drugs by vein to lower blood pressure as soon as possible.
When blood pressure is checked, two values are recorded. The higher value reflects the highest pressure in the arteries, which is reached when the heart contracts (during systole). The lower value reflects the lowest pressure in the arteries, which is reached just before the heart begins to contract again (during diastole). Blood pressure is written as systolic pressure/diastolic pressure—for example, 120/80 mm Hg (millimeters of mercury), referred to as 120 over 80.
A hypertensive emergency is a particularly severe, sudden form of high blood pressure. Diastolic blood pressure (the bottom number) is usually over 100 mm Hg, and there is evidence of progressive damage in one or more vital organs (typically the brain, heart, eyes, and kidneys). Children may have a variety of symptoms.
Hypertensive emergencies are relatively rare in children. They may develop in children who have or have not been previously diagnosed with high blood pressure.
Hypertensive emergencies usually occur when blood pressure rapidly increases. What causes the rapid increase varies by age. The most common causes are
During infancy: Birth defects of the kidneys, bronchopulmonary dysplasia, coarctation of the aorta, renal vein thrombosis, and other disorders that affect the blood vessels to the kidneys
During childhood: Kidney tissue disease, disorders that affect the blood vessels to the kidneys, hormonal disorders, drugs, and toxins
anabolic steroids, corticosteroids, or certain oral contraceptives (birth control pills)
A hypertensive emergency, if not treated promptly, typically causes progressive damage in one or more vital organs, particularly the following:
Brain, which can result in deterioration of brain function, seizures, and/or coma
Heart, which can result in heart failure
Eyes, which can result in papilledema (swelling of the optic nerve) and bleeding in the retina
Kidneys, which can result in kidney dysfunction or failure
If untreated, a hypertensive emergency can be fatal.
A hypertensive urgency is severe high blood pressure that has not yet caused enough organ damage to result in symptoms.
Symptoms of Hypertensive Emergencies in Children
Blood pressure is very high, typically at a stage 2 (severe) high blood pressure level or higher (140/90 or higher).
In children, the first symptoms of a hypertensive emergency are typically a headache, listlessness (lethargy), confusion, seizures, and, in infants, irritability. Children may go into a coma.
Children may have a rapid heart rate, chest pain, shortness of breath, and/or swollen ankles. Vision may be impaired.
Diagnosis of Hypertensive Emergencies in Children
Blood pressure measurement
Tests to evaluate organ damage
During a suspected hypertensive emergency, doctors use an oscillometer to measure blood pressure rather than using a stethoscope. The oscillometer records blood pressure automatically and quickly, which helps with the measuring that is needed (every 2 to 3 minutes). Blood pressure is measured again using a sphygmomanometer and a stethoscope to confirm the measurement. When possible, doctors do intra-arterial blood pressure monitoring, which involves putting a small plastic tube inside an artery and connecting it to a pressure monitor. These arterial pressure monitors measure blood pressure continuously and are also more accurate than other devices.
Doctors take a medical history, which includes questions about the child's current symptoms, any disorders the child has, and any drugs the child takes.
A thorough physical examination and standard blood and urine tests are done.
Tests are also done to determine whether vital organs are damaged and, if so, how much damage is present. Tests include
Electrocardiography (ECG), chest x-ray, and, if possible, an echocardiography to check for heart disorders
Urinalysis to screen for kidney abnormalities
Blood tests to check for kidney damage or hormonal abnormalities
Complete blood count to check for abnormal numbers of blood cells, particularly platelets (which help blood clot)
Computed tomography (CT) or magnetic resonance imaging (MRI) of the head to check for a mass or hemorrhage in the brain and to rule out other possible causes of symptoms related to the brain
Drug and pregnancy tests in adolescents
If the child's high blood pressure has not previously been diagnosed or evaluated, other testing to determine the cause of the high blood pressure can be done later.
Treatment of Hypertensive Emergencies in Children
For hypertensive emergencies, admission to an intensive care unit and intravenous drugs to lower blood pressure
For hypertensive urgencies, admission to an emergency department or hospital and oral drugs to lower blood pressure (occasionally intravenous drugs are needed)
Children with a hypertensive emergency are rapidly admitted to an intensive care unit (ICU) or, if an ICU is not available, to an emergency department so that they can be quickly treated and evaluated and monitored closely. There, drugs to lower blood pressure (antihypertensive drugs) can be given by vein (intravenously) as soon as possible.
The goal of treatment of hypertensive emergencies is to lower blood pressure enough to eliminate the risk of life-threatening symptoms and to stop further damage to vital organs.
Once blood pressure has been lowered, doctors can give children drugs by mouth (orally).
Children with a hypertensive urgency (severe hypertension but no symptoms and no organ problems) also are admitted to a hospital or emergency department and are evaluated immediately, but blood pressure does not need to be lowered as quickly as for a hypertensive emergency. These children are typically given drugs by mouth. Occasionally, intravenous drugs are needed.
If possible, children with either disorder should be treated by a doctor or specialist experienced in managing severe high blood pressure in children.
Drugs for Hypertensive Emergencies in Children
Type | Drug* | Some Side Effects |
|---|---|---|
May cause an abnormally slow heart rate or wheezing | ||
May cause a fast heart rate | ||
Headache, fast heart rate | ||
Sodium nitroprusside† | May cause cyanide toxicity when used for more than 72 hours, or when used in children with kidney failure May increase pressure in the skull | |
May cause a severely abnormally slow heart rate | ||
* These drugs are given by vein (intravenously). | ||
Drugs for Hypertensive Urgencies in Children
Type | Drug* | Some Side Effects |
|---|---|---|
Significant drowsiness, fatigue, dizziness, dry mouth | ||
Headache, fast heart rate | ||
Common side effects: Flushing, swelling of the lower legs or hands Severe side effects: Angioedema (allergic swelling that affects the face, lips, and windpipe and may interfere with breathing) | ||
Common side effects: Dizziness, too low blood pressure, fluid retention Severe side effects: Heart failure, fluid retention in the lungs, Stevens-Johnson syndrome | ||
* These drugs are given by mouth (orally). | ||
