4 hypertensive kids in 45 minutes. name: anthony age: 6 sex: male place: allergy clinic bp: 145/87

4 Hypertensive Kidsin 45 Minutes

Name: Anthony

Age: 6

Sex: Male

Place: Allergy Clinic

BP: 145/87

Name: Chris

Age: 17

Sex: Male

Place: Inpatient

BP: 180/115

Name: Brittiney

Age: 13

Sex: Female

Place: Clinic

BP: 125/78

Name: Caleb

Age: 3

Sex: Male

Place: Phone Call

BP: 118/75

Caleb

AnthonyBrittiney

Chris

The Fourth Task Force Report on Pediatric High Blood Pressure

http://www.nccpeds.com/

6 Questions

• Does the child really have high blood pressure?

• Do I have time to ask any more questions?• Why does the child have high blood

pressure? • Does the child have other risk factors? • What has high blood pressure already

done to the child's body? • What should we do about it?

Blood Pressure Measurement Technology is in the Dark Ages.

Confirm all blood pressure readings before acting.

It’s a Pain in the A** to Detect HTN

Equipment is inherently flawed, hard to findOr gives inaccurate readings if not used right.


Spurious elevations are common


Not everyone has a BP reading.


Mild Hypertension takes weeks to confirm


Norms for Pediatric BP are found in a 4-D table

It’s a Pain, But you Got to Do it

http://www.statcoder.com/growthcharts.htm

Normal

< 90% le

Pre-Hypertension

90-95% le

Stage 1 Hypertension95% to 5 mm above 99%le

Stage 2 Hypertension> 5 mm above 99%le

Hypertension is Common

02468

101214161820

Hypertension Asthma

%

Caleb118/75

Anthony145/87

Brittiney125/78

Chris180/115

161 cm (72%le)

95% BP = 126/8290% BP = 122/78

114 cm (75%le)

168 cm (16%le)

98 cm (64%le)

95% BP = 113/7499% BP = 120/82

95% BP = 133/8599% BP = 141/93

95% BP = 110/6799% BP = 118/75

Recognizing or ruling out a hypertensive emergency is the 1st

order of business in any hypertension evaluation.

6 Questions





Is this an Emergency?

Hypertensive Emergency

Elevated Blood Pressure with symptoms of end-organ damage

Hypertensive Urgency

A high BP that makes you uncomfortable

Hypertensive Emergencies

• Drop the Blood Pressure no more than 10%

• Use short acting IV medications– IV Labetolol– IV Hydralazine– IV Nicardipine drip

• Start small and then escalate your dose

• Get the patient to a PICU

Chris

Chest Pain and a splitting headache

Labetolol and hydralazine given on the floor – no effect. Nicardipine drip in PICU. BP 150s/80s by noon.

6 Questions





School Age Teenager

Chronic UTIs

GlomerularDisease

RenovascularDisease

Aortic Coarctation

Essential Hypertension

Essential Hypertension

GlomerularDisease

RenovascularDisease

Other Causes of Pediatric Hypertension that you still think about• Inpatients

– Increased ICP– Pain– Iatrogenic steroid-induced

• Uncommon outpatient causes– Endocrine causes (Cushing, Pheo)– Pre-eclampsia

The Younger the Patient with Hypertension,

the More Likely you’ll find a Cause

Rule of Thumb #1

The Higher the Blood Pressure,

the more likely there’s a cause

Rule of Thumb #2

Symptoms to Ask About

History

UAC as a newborn

UTIs or febrile illnesses

Medications

Supplements

Family History

Physical

Arm & Leg BPs

A

B

C

What’s Normal?

1. A = B = C

2. A = B > C

3. A = B < C

4. A > B > C

What’s Normal?

1. A = B = C

2. A = B > C

3. A = B < C

4. A > B > C

Eye Grounds

Heart Findings

Listen for a Bruit

Skin

CALMs of NF-1Acanthosis Nigricans

Labs & Imaging

Pre-Hypertension

Lipids Fasting Glucose Echocardiogram Retinal Exam

Young Stage 1 or Stage 2

Renin CatecholaminesAngiogram Urine Steroids

+

Teenager Stage 1

RFP Urinalysis Renal Ultrasound+

Pre-Hypertension

Lipids Fasting Glucose Echocardiogram Retinal Exam

LVH on an echocardiogram is the most common end-organ manifestation in pediatric hypertension

Essential hypertension almost always occurs with other risk factors

Teenager Stage 1

RFP Urinalysis Renal Ultrasound

Quantitate any abnormal urine protein

There’s no normal creatinine in pediatrics, but there is a normal GFR.

Renal vessel doppler are of questionable value.

Young Stage 1 or Stage 2

Renin CatecholaminesAngiogram Urine Steroids

Plasma renin is usually uninterpretable.

Elevated urine catecholamines are usually transient and not subtle.

Don’t bother with MRAs or nuclear scans; the gold standard is an angiogram.

Caleb

Category of HTN: Young Stage 1History & Symptoms: NonePhysical: NormalLabs: NormalImaging:

Echo: Mild LVHU/S: Left kidney < RightAngio: Normal

Brittiney

Category of HTN: Pre-HypertensionHistory & Symptoms: SnoresPhysical: Elevated BMI ~ 98%le

Labs: Fasting BG 121Imaging:

Echo: NormalU/S: Normal

Life-style changes

Give a TV target of 2 hours per day or less

Write a prescription for PE

DASH diet (http://www.nhlbi.nih.gov/)

Surveillance

Lipids, Blood Sugars, Weight, Urine Protein

Ambulatory Blood Pressure Monitor (ABPM)

Ambulatory Blood Pressure Monitor

Anthony

Category of HTN: Young Stage 2History & Symptoms: Intermittent headaches

Physical: Single Café au LaitLabs: NormalImaging:

Echo: Moderate LVHU/S: NormalAngio:

Chris

Category of HTN: Teenager Stage 2History & Symptoms: Transplant;

On a dripPhysical: TachycardicLabs: Creatinine 1.7Imaging:

U/S:

Chris

Hydronephrosis, Ureteral obstruction

Blood pressure dramatically better (off drips) after nephrostomy

6 Questions





7 Classes of Anti-hypertensives

• Diuretics• Beta-blockers IV labetolol• Central Alpha-Blockers• Calcium Channel Blockers nicardipine

drip• ACE Inhibitors• Direct Vasodilators IV hydralazine• Angiotensin Receptor Blockers• Peripheral Blockers

Take Home Points

• Report the percentile of Blood Pressure on Any BP you get

• Recognize a hypertensive emergency

• Refer to the 4th Task Force Report or your local pediatric nephrologist once you recognize a high blood pressure

4 hypertensive kids in 45 minutes. name: anthony age: 6 sex: male place: allergy clinic bp: 145/87

Documents

common slide

high bp

picu slide

minutes slide

uncomfortable slide

blood pressure readings

pediatric bp

inpatient bp