Hypertension
High blood pressure
(Cardio Ex, Renal Ex, Neuro Ex)
Primary = no cause identified
Secondary = cause identified
Associated with aortic and coronary atherosclerosis (grain+hard)
For diagnosis must be on 3 or more occasions, and is based of gender, age and ht
Normotensive = SBP and DBP <90th centile
PreHTN = either 90-95th centile or >120/80
Hypertension (Stage 1 usually primary, Stage 2 aka severe usually secondary)
First is it a hypertensive emergency/urgency
Hypertensive emergency = HTN with evidence of potentially life threatening symptoms OR acute target organ damage
CHECK CUFF
? Coarctation > 4 limb BP/pre+post ductal sats ?ECHO
? raised ICP i.e. bleed/mass Ex Cushings triad HR, RR, neuro deficit
? Glomerularnephritis / nephritic syndrome > oedema, UA, Cr
? symphathomemetic i.e. cocaine, amphetamines, PCP > Hx, drug urine screen
? Eclampsia > BhCG
? renovascular disease > abdo/flank bruit
FBE/EUC
ECG
Rx Emergency
Non-emergent, non-urgent
Identify secondary causes (prepubertal generally secondary, post pubertal generally primary)
Identify comorbidities
Hx Umb catheter, Stress,
FH MI/CVA/HTN/DM
epistaxis, dyspnoea (failure)
Hearing loss (Alports, Lead nephropathy, congenital rubella, ?aminoglycoside toxicity)
drugs: Cocaine, amphetamines, anabolic steroids, phencyclidine, ephedra-containing alternative medications, caffeine, oral contraceptives, corticosteroids
Throat/skin infection (PSGN)
Diarrhoea (HUS)
Rash (HSP, Lupus)
BMI, BSL, Cholesterol, BhCG, EUC,
ECG (LVH) ?ECHO
UA, ?DMSA
Ophthal: hypertensive retinopathy
Most warrant renal referral
Ix
ALL
EUC FBE VBG
UA
Renal US
ECHO to look for LVH (will also exclude coarc)
Holter (if nocturnal HTN or no nocturnal dip or diastolic HTN more likely secondary, rules out white coat)
If ? secondary (i.e. prepubertal, stage 2 HTN, findings indicative of a specific underlying cause)
Plasma renin, aldosterone (above + ↓K or metabolic alkalosis
DMSA if recurrent UTIs or suggestion of scarring on renal US
Plasma and urine catecholamines (only if sympathetic symptoms eg, headache, sweating, and/or tachycardia or risk e.g. NF)
MRA (or Renal Dopplers but not as sensitive) if no other cause found or if Umb cath/NF/renal bruit
Renal biopsy as per renal team
Rx
Target <90th centile if
- pril ACEi
- alol B-blocker
- sartan ATIIRB
(Cardio Ex, Renal Ex, Neuro Ex)
Primary = no cause identified
Secondary = cause identified
Associated with aortic and coronary atherosclerosis (grain+hard)
For diagnosis must be on 3 or more occasions, and is based of gender, age and ht
Normotensive = SBP and DBP <90th centile
PreHTN = either 90-95th centile or >120/80
Hypertension (Stage 1 usually primary, Stage 2 aka severe usually secondary)
- Stage 1 HTN = 95th - 5mmHg above 99th centile
- Stage 2 HTN = > 5mmHg above 99th centile (to differential urgency from emergency see below)
- Urgency
- Emergency
First is it a hypertensive emergency/urgency
Hypertensive emergency = HTN with evidence of potentially life threatening symptoms OR acute target organ damage
- brain (increased intracranial pressure, encephalopathy: irritability, lethargy, coma, seizures)
- cerebrovascular breakdown > oedema or bleed > ↑ ICP > encephalopathy or focal neurology
- eyes (papilledema, retinal hemorrhages, exudates)
- heart (heart failure)
- kidneys (renal insufficiency)
- may have headache, nausea
- sympathetic symptoms: palpitations, tachycardia, flushing ?Pheo
- oedema, haematuria, proteinuria ?glomerularnephritis
- if chronic correct with PO over 1-2 days (to prevent hypoxia stroke)
CHECK CUFF
? Coarctation > 4 limb BP/pre+post ductal sats ?ECHO
? raised ICP i.e. bleed/mass Ex Cushings triad HR, RR, neuro deficit
? Glomerularnephritis / nephritic syndrome > oedema, UA, Cr
? symphathomemetic i.e. cocaine, amphetamines, PCP > Hx, drug urine screen
? Eclampsia > BhCG
? renovascular disease > abdo/flank bruit
FBE/EUC
ECG
Rx Emergency
- ABCs
- Cardiorespiratory monitoring, pulse oximetry, 1 minutely BPs
- IVCs x 2
- IV Anti HTN (Labetalol or Hydralazine)
- Art line (don't delay IV antiHTN for this)
- Max drop of 25% of the planned total BP reduction over the first 8 hours (generally aim for between 95-99th centile) (
- Consult ICU and Renal Team
Non-emergent, non-urgent
Identify secondary causes (prepubertal generally secondary, post pubertal generally primary)
Identify comorbidities
Hx Umb catheter, Stress,
FH MI/CVA/HTN/DM
epistaxis, dyspnoea (failure)
Hearing loss (Alports, Lead nephropathy, congenital rubella, ?aminoglycoside toxicity)
drugs: Cocaine, amphetamines, anabolic steroids, phencyclidine, ephedra-containing alternative medications, caffeine, oral contraceptives, corticosteroids
Throat/skin infection (PSGN)
Diarrhoea (HUS)
Rash (HSP, Lupus)
BMI, BSL, Cholesterol, BhCG, EUC,
ECG (LVH) ?ECHO
UA, ?DMSA
Ophthal: hypertensive retinopathy
Most warrant renal referral
Ix
ALL
EUC FBE VBG
UA
Renal US
ECHO to look for LVH (will also exclude coarc)
Holter (if nocturnal HTN or no nocturnal dip or diastolic HTN more likely secondary, rules out white coat)
If ? secondary (i.e. prepubertal, stage 2 HTN, findings indicative of a specific underlying cause)
Plasma renin, aldosterone (above + ↓K or metabolic alkalosis
DMSA if recurrent UTIs or suggestion of scarring on renal US
Plasma and urine catecholamines (only if sympathetic symptoms eg, headache, sweating, and/or tachycardia or risk e.g. NF)
MRA (or Renal Dopplers but not as sensitive) if no other cause found or if Umb cath/NF/renal bruit
Renal biopsy as per renal team
Rx
Target <90th centile if
- CVD risks: Overweight, FHx +, dyslipidemia, T1/T2DM, CKD, Kawasaki's
- End organ damage: LV hypertrophy, proteinuria, renal scarring,
- pril ACEi
- alol B-blocker
- sartan ATIIRB