Transcript Pediatric Hypertension

4 Hypertensive Kids
in 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
Brittiney
Anthony
Chris
Caleb
The Fourth Task Force Report on
Pediatric High Blood Pressure
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?
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 find
Or gives inaccurate readings if not used right.
It’s a Pain in the A** to Detect HTN
Spurious elevations are common
It’s a Pain in the A** to Detect HTN
Not everyone has a BP reading.
It’s a Pain in the A** to Detect HTN
Mild Hypertension takes weeks to confirm
It’s a Pain in the A** to Detect HTN
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
Stage 2 Hypertension
> 5 mm above 99%le
Stage 1 Hypertension
95% to 5 mm above 99%le
Pre-Hypertension
90-95% le
Normal
< 90% le
Hypertension is Common
%
20
18
16
14
12
10
8
6
4
2
0
Hypertension Asthma
Brittiney
125/78
161 cm
95% BP = 126/82
90% BP = 122/78
Anthony
145/87
114 cm
Chris
180/115
168 cm
Caleb
118/75
(72%le)
(75%le)
95% BP = 113/74
99% BP = 120/82
(16%le)
95% BP = 133/85
99% BP = 141/93
98 cm
(64%le)
95% BP = 110/67
99% BP = 118/75
Recognizing or ruling out a
hypertensive emergency is the 1st
order of business in any
hypertension evaluation.
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?
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
• 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?
School Age
Teenager
Chronic UTIs
Essential Hypertension
Glomerular
Disease
Glomerular
Disease
Renovascular
Disease
Renovascular
Disease
Aortic Coarctation
Essential Hypertension
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
Rule of Thumb #1
The Younger the Patient
with Hypertension,
the More Likely you’ll find
a Cause
Rule of Thumb #2
The Higher the Blood Pressure,
the more likely there’s a cause
Symptoms to Ask About
History
UAC as a newborn
UTIs or febrile illnesses
Medications
Supplements
Family History
Physical
Arm & Leg BPs
B
What’s Normal?
1. A = B = C
A
2. A = B > C
C
3. A = B < C
4. A > B > C
Eye Grounds
Heart Findings
Listen for a Bruit
Skin
CALMs of NF-1
Acanthosis Nigricans
Skin
Labs & Imaging
Young Stage 1 or Stage 2
Renin
Angiogram
Catecholamines
Urine Steroids
+
Teenager Stage 1
RFP
Urinalysis
Renal Ultrasound
+
Pre-Hypertension
Lipids Fasting Glucose
Echocardiogram
Retinal Exam
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
Angiogram
Catecholamines
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 1
History & Symptoms: None
Physical:
Normal
Labs:
Normal
Imaging:
Echo:
Mild LVH
U/S:
Left kidney < Right
Angio:
Normal
Brittiney
Category of HTN:
History & Symptoms:
Physical:
Labs:
Imaging:
Echo:
Normal
U/S:
Normal
Pre-Hypertension
Snores
Elevated BMI ~ 98%le
Fasting BG 121
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:
History & Symptoms:
Physical:
Labs:
Imaging:
Echo:
Moderate
U/S:
Normal
Angio:
Young Stage 2
Intermittent headaches
Single Café au Lait
Normal
LVH
Chris
Category of HTN:
History & Symptoms:
Physical:
Labs:
Imaging:
U/S:
Teenager Stage 2
Transplant;
On a drip
Tachycardic
Creatinine 1.7
Chris
Hydronephrosis, Ureteral obstruction
Blood pressure dramatically better
(off drips) after nephrostomy
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?
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