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 effects on the brain, heart, and kidneys (electrocardiography, echocardiography, brain CT scan or MRI, and blood and urine tests).
Treatment of hypertensive emergencies involves admitting children to an intensive care unit and giving medications by vein to lower blood pressure as soon as possible.
When blood pressure is checked, 2 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. Blood pressure may be 30 points or more higher than what is needed to diagnose hypertension, 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, medications, and toxins
During adolescence: Kidney tissue disease, not taking medications they were prescribed for their high blood pressure, and use of medications such as stimulants (for example, amphetamines and cocaine), 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.
Together hypertensive urgencies and hypertensive emergencies are called acute severe hypertension.
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).
Children with severe high blood pressure may not have any symptoms or they may have severe symptoms. Symptoms may be related to the age of the child. In infants and young children, the first symptoms of a hypertensive emergency may be nonspecific including irritability, poor feeding, or growth and weight faltering. Younger children may also have a change of consciousness or seizures. Older children may have a headache, vision changes, dizziness, listlessness (lethargy), or nausea and vomiting.
Children may have a rapid heart rate, chest pain, shortness of breath, and/or swollen ankles. Children may go into a coma.
All children with a hypertensive emergency have evidence of organ damage. In children with a hypertensive urgency, organ damage may not be present.
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 medications 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 exclude 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, medications to lower blood pressure (antihypertensive medications) 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. Doctors make sure that the blood pressure is not lowered too quickly, which can also cause inadequate blood flow to the brain or kidneys.
For hypertensive emergencies, the preferred intravenous medications are labetalol and nicardipine.For hypertensive emergencies, the preferred intravenous medications are labetalol and nicardipine.
If the preferred medications cannot be used or do not work, sodium nitroprusside, hydralazine, and esmolol are other intravenous medications that may be used.If the preferred medications cannot be used or do not work, sodium nitroprusside, hydralazine, and esmolol are other intravenous medications that may be used.
Once blood pressure has been lowered, doctors can give children medications 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 medications by mouth. Occasionally, intravenous medications are needed.
For hypertensive urgencies, clonidine, hydralazine, isradipine, or minoxidil is given by mouth. Sometimes intravenous medications are used either in place of oral medications or in addition to them.For hypertensive urgencies, clonidine, hydralazine, isradipine, or minoxidil is given by mouth. Sometimes intravenous medications are used either in place of oral medications or in addition to them.
When possible, children with either disorder should be treated by a doctor or specialist experienced in managing severe high blood pressure in children.
Medications for Hypertensive Emergencies in Children
Type | Medication* | Some Side Effects |
|---|---|---|
LabetalolLabetalol | May cause an abnormally slow heart rate or wheezing | |
NicardipineNicardipine | May cause a fast heart rate May raise cyclosporine or tacrolimus levels in the blood of children who take these medicationsMay raise cyclosporine or tacrolimus levels in the blood of children who take these medications | |
Hydralazine†Hydralazine† | 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 | |
Esmolol†Esmolol† | May cause a severely abnormally slow heart rate | |
Enalaprilat† | May cause dizziness and low blood pressure. | |
* These medications are given by vein (intravenously). | ||
† This medication is used if labetalol or nicardipine cannot be used or does not work.† This medication is used if labetalol or nicardipine cannot be used or does not work. | ||
Medications for Hypertensive Urgencies in Children
Type | Medication* | Some Side Effects |
|---|---|---|
ClonidineClonidine | Significant drowsiness, fatigue, dizziness, dry mouth | |
HydralazineHydralazine | Headache, fast heart rate | |
IsradipineIsradipine | 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) | |
Minoxidil Minoxidil | Common side effects: Dizziness, too low blood pressure, fluid retention Severe side effects: Heart failure, fluid retention in the lungs, Stevens-Johnson syndrome | |
* These medications are given by mouth (orally). | ||
