1. Hypertension National Pediatric Nighttime Curriculum Written by: H. Barrett Fromme, MD, MHPE The University of Chicago

2. Case 1 You are the intern and are paged at 8pm: “FYI: The patient in Room 678 has a BP of 125/82.– Nurse Mike” Signout: 11yo male here for asthma exacerbation. Meds: Albuterol q3h, Prednisone 60mg What Else Do You Want To Know?

3. Case 2 “The 8mo in room 502 is having blood pressures as high as 113/62. Can I get your opinion? – J. Intern” Signout:  8mo female ex 26wk premie admitted for labial abscess  Wt: 6.4kg, Length 64cm As you walk to the patient’s room, what is your differential? What questions do you have for the nurse? When would you be concerned enough to intervene?

4. Objectives Describe the initial steps in evaluation of inpatient hypertension Identify scenarios when medical therapy is warranted for inpatient hypertension Select pharmacologic therapy for hypertensive urgency and emergency

5. On Call Hypertension Primer

6. Hypertension Definitions* Prehypertension:  SBP and/or DBP between 90 th and 95 th % Stage 1 Hypertension:  SBP and/or DBP ≥ 95 th %, but ≤ 99 th % + 5mm Stage 2 Hypertension:  SBP and/or DBP > 99 th % + 5mm *All based on gender, height and age (see references)

7. More Definitions Hypertensive Urgency:  Severe elevation (Stage 2) without end-organ damage Hypertensive Emergency  Severe elevation (Stage 2) with any signs of end-organ damage End Organ Damage signs, symptoms includes:  CNS (headache, seizure, lethargy, irritability)  Eyes (papilledema, visual changes)  Cardiac (cough, SOB, signs of heart failure, gallop, abdominal bruit)  Renal (hematuria, proteinuria)

8. Initial Approach Start by seeing the patient Confirm blood pressure  Manual reading with auscultation  Appropriate size cuff Assess blood pressure trends  Current and prior data points Assess for other secondary causes  Pain  Drugs  Increased ICP  Coarctation of the aorta Look for symptoms of end-organ damage  Classify as emergency, urgency or just hypertension

9. Differential Diagnosis Renal  Parenchymal ds  Congenital anomaly Cardiovascular  Coarctation  Renal artery stenosis  AV fistula Psychological  Stress, Anxiety Endocrine  DM  Hyperaldosteronism  Cushing Syndrome Neurologic  Increased ICP  Pain Pharmacologic  Steroids Other  White Coat common in hospital

10. Management Hypertensive Urgency  Preferentially obtain IV access Oral could be used if tolerating po (Clonidine, Isradipine)  If acute, treat medically: Hydralazine 0.2mg/kg/dose IV (max 20mg/dose) Labetolol 0.2mg/kg/dose IV (max 20mg/dose)  If chronic (long-standing renal ds, etc) Consult with Nephrology Oral medications potentially  Clonidine

11. Management Hypertensive Emergency  Obtain IV access  Give either: Hydralazine 0.2mg/kg IV (max 20mg/dose) Labetolol 0.2mg/kg IV (max 20mg/dose)  Transfer to ICU for IV medications

12. On-Call Hypertension Algorithm Flynn, JT, Tullus, K. Severe hypertension in children and adolescents: pathophysiology and treatment. Pediatr Nephrol 2008

13. Big Picture The on call job is to identify urgencies/emergencies and treat as needed Always interpret blood pressure by age and height-based norms Work-up can be done less acutely if patient stable

14. Take Home Points Always recheck BP manually with appropriate cuff Treat underlying causes if exist Urgency and Emergency require treatment End-organ symptoms = Hypertensive Emergency = ICU

15. References National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004; 114: 555- 576. Constantine E, Linakis J. The assessment and management of hypertensive emergencies and urgencies in children. Pediatr Emerg Care. 2005; 21: 391-396.

16. Questions 1. Which of the following is the appropriate cuff sizing for measuring blood pressure? a.A cuff whose height that is 80% the length of the upper arm b.A cuff bladder that’s length is 80% of the arm circumference c.A cuff width that is 50% of the arm circumference d.A cuff bladder that is 25% the arm circumference

17. Questions (B) An appropriate cuff size is based on the bladder size, which should have a length that is 80% the circumference of the arm. Cuff bladder width should be 40% of the arm circumference. An incorrect cuff size (too small) can give falsely elevated blood pressures.

18. Questions 2. What is the definition of Stage I Hypertension? a.SBP/DBP >85 th % but <90 th % for height and age b.SBP/DBP > 90 th %, but <95 th % for height and age c.SBP/DBP >95 th % but <99 th % for height and age d.SBP/DBP >99 th % for height and age

19. Questions C)Stage I Hypertension is a blood pressure that is >95% but <99% of the age/weight based norms. Prehypertension is between the 90 th and 95 th %.

20. Questions 3. What features separate a hypertensive urgency from an emergency? a.Percentile of blood pressure b.Duration of elevation c.Signs of end organ involvement d.A & C e.All of the above

21. Questions (C)Signs of end-organ damage are what differentiate Hypertensive Urgency from Emergency, and thus determine the need for emergency treatment. Hypertensive Urgency can be treated with oral or IV medications on the floor with individual doses. Hypertensive Emergency requires more monitored IV treatment in an ICU setting.

22. Questions 4. Which of the following is not potentially a sign of end organ involvement? a.Seizure b.Irritability c.Vomiting d.Respiratory distress e.None of the above

23. Questions (C)Signs of end-organ damage are seen in several systems, including CNS, Renal, Cardiac and Eyes. The most obvious include mental status changes, such as irritability in infants and children, seizures, and signs of heart failure, including respiratory distress. Vomiting is not considered a sign of end-organ damage, though it may reflect increased ICP which is a secondary cause of HTN.

24. Questions 5. Which of the following medications does not cause hypertension? a. Prednisone b. Propanolol c. Oral contraceptives d. Ceftriaxone e. Cocaine

25. Questions (D)Though many medications can cause hypertension, Ceftriaxone does not have the side effect. The rest of the choices are in therapeutic categories, that through a variety of mechanisms, can increase blood pressure.

26. Questions 6. Which of the following hypertensive scenarios requires immediate treatment? a. A 3yo with h/o renal disease and Stage I HTN, now with SBP > 99th% b. A 2mo admitted for labial abscess with SBP > 99th% and tachycardia c. A 10yo admitted for asthma with SBP at 98th% with tachypnea d. A 1yo admitted for bronchiolitis with SBP > 99th% with lethargy

27. Questions (D)The most likely of these to need immediate treatment is the bronchiolitic who has a Hypertensive Emergency -- the elevation of the BP combined with the end-organ symptom of lethargy is highly concerning, especially in a setting of few other causes. Though (B) could be considered a Hypertensive Urgency, the blood pressure is likely increased by the pain associated with the abscess, and therefore pain medications could be tried first. The asthmatic only has Stage I Hypertension, which is most likely influenced by the steroid treatment of asthma, and his tachypnea is likely due to the asthma. Finally, the patient with a h/o HTN and renal failure would be considered a chronic patient, and though oral medications could be used, a conversation with the nephrologist should be had.