Hypertension Flashcards
What is considered elevated BP in a child?
Stage 1 (> or = 95%le) Stage 2 (> or = 99%le or > 99%le + 5 mm Hg)
Define hypertensive urgency
Severely elevated BP with NO end organ damage
Define a hypertensive emergency
Severely elevated BP with end organ damage
If there is an initial high BP, what two other questions do you need to ask?
1) What size of cuff did you use?
- Falsely elevated if cuff is too small, or falsely low if cuff is too big
- Width should be 40% of the circumference of the arm at the midpoint between the shoulder and elbow
- Cuff should encircle 80-100% of the circumference of the upper arm or 2/3 of its length
2) Will you please repeat it?
- multiple causes of elevated BP that are transient - pain,, anxiety, white coat, heat, agitation, recent activity
Who needs workup and/or treatment for hypertension?
Workup and treatment - Hypertensive Urgency or emergency
- ABCs and IV access
Workup ONLY - ASmxtc Stage 2 HTN
- Hx, PEx, screening bloodwork - if normal, DC with follow up
Discharge without Workup - patients being seen for another problem who are incidentally found to have Stage 1 HTN and are ASxmtc - DC to the care of their GP to reassess
Name the pathologic causes of hypertension
HYPERTENSION
H: Hyperthyroidism (and other autoimmune diseases)
Y: Why? Cause unknown - Primary Hypertension
P: Pheochromocytoma
E: Eats too much - obesity
R: Renal parenchyma disease
T: Thrombosis (Renal artery, especially if had an umbilical
catheter as a neonate)
E: Endocrine disorder ( Congenital adrenal hyperplasia,
primary aldosteronism, hyperparathyroidism)
N: Neurologic disorder ( increased ICP, Guillain-Barre, NF)
S: Stenosis (renal artery stenosis, coarctation of the aorta,
supravalvular aortic stenosis with William’s syndrome)
I: Ingestion (cocaine, sympathomimetics, birth control pills,
steroids, decongestants, sudden withdrawal,
chemotherapy)
O: Obstetric causes (eclampsia)
N: Neuroblastoma
What symptoms do patient with hypertension present with?
Asymptomatic - incidental finding Irritability Headache Visual disturbances Personality changes Dizziness N/V Weight loss Polyuria Polydipsia Facial nerve palsy Seizure Coma
What are important questions to ask for hypertension?
Hx of recurrent UTIs, unexplained fevers, hematuria, frequency, dysuria, recent illness, sore throats, chest pain, shortness of breath
Hx of umbilical catheter as a neonate
Sx of intermittent sweating, flushing and palpitations
Poor growth?
Any recent head trauma
FHx of HTN, renal disease of deafness
Any ingestions
Important PEx findings for hypertension
General: dysmorphism (elfin faces of William’s syndrome), cushingoid features, over/underweight
HEENT: evidence of head trauma, decreased visual acuity, papilledema, retinal infarcts, abnormal pupillary reflex
Neck: webbed neck, thyroid enlargement
Lungs: crackles (evidence of ventricular failure), increased WOB
Heart: displaced point of maximal impulse (LVH), murmurs
Abdomen: bruits, hepatomegaly, abdominal masses
Renal: flank pain
Back: signs of spina bifida
Extremities: decreased femoral pulses, discrepant 4 limb BPs, edema
Skin: cafe au lait spots or skinfold freckling (NF), xanthomas (hyperlipidemia), hirsutism, purpuric rash on lower extremities
Neurologic: HA, seizures, altered LOC, encephalopathy, CN palsies, sensorimotor asymmetry, hyperreflexia
Ix needed for Hypertension
UA and Cx (if indicated)
Lytes, BUN, Cr, +/- lipid profile
ECG and CXR - if Sxmtc
Renal US
How quickly do you want to lower the BP?
No more than 25% of the initial value in the 1st hour
Goal to < 95th percentile to avoid end organ damage - over 24-48h
Dropping the BP too quick can lead to cerebral ischemia due to changes in the set point of autoregulation of the brain blood vessels (normally - when BP lowers BBV dilate, when BP goes higher BBV constrict)
Describe your approach to managing a hypertensive emergency
ABCDE Nifedipine PO (test dose first – 0.05 mg/kg) OR Hydralazine IV (0.1*-0.2 mg/kg) OR Labetalol IV 0.1*-0.2 mg/kg
To reduce BP by no more than 25% from presenting values.
*A lower initial dose is recommended, especially in the absence of intra-arterial BP monitoring
IV furosemide 1-2 mg/kg, MAX 40-80 mg if fluid overloaded e.g. post- strep GN and renal failure
IV lorazepam 0.05 mg/kg, MAX 4 mg if seizures
Name appropriate medications that can be used for Hypertensive Urgency and Emergency (name, type, route, onset/duration, mechanism of action, indications and contraindications)
HTN URGENCY
1) Nifedipine:
CCB, PO/SL, Onset: 10-30 min, Duration: 4-8h, Mech: Coronary vasodilatation, reduces peripheral vascular resistance, IND: When IV not available, CONT: Cardiogenic shock, myocardial infarction
2) Clonidine:
Central alpha-2 agonist, PO, Onset 15-30 min, Duration: 6-8h, Mech: reduces cerebral sympathetic output, IND: hemodialysis patients, HTN related to pain, anxiety, drug withdrawal, CON: may cause sedation
3) Furosemide:
Rapid acting diuretic, IV/PO, minutes, Mech: Diuretic, inhibits NaCl and water reabsorption, IND: HTN with fluid overload in addition to anti-HTNsives
HTN EMERGENCY
1) Nicardipine
CCB, IV (titrate), Onset: 1-10 min, Duration: 2-4 hours, Mech: arterial vasodilator, promotes cerebral and coronary dilation, decreases SVR, IND: acute severe HTN, perioperative HTN, stroke or intracranial hemorrhage related HTN, acute renal failure, sympathetic crisis, CON: hypovolemia, may cause reflex tachycardia
2) Labetolol
Alpha and beta blocker, IV (titrate)., Onset: 2-10 min, Duration: 2-6 hours, Mech: decreases SVR, IND: acute severe HTN, stroke or intracranial hemorrhage related HTN, CON: Asthma, CHF
3) Sodium nitroprusside
Vasodilator, IV (titrate), Onset: <1-2 mins, Duration: < 10 mins, Mech: direct venous and arterial vasodilator, IND: Acute severe HTN, CHF pulmonary edema, CON: Intracranial hypertension, may cause cyanide toxicity
4) Esmolol
Beta blocker, IV (titrate), Onset: 1-2 min, Duration: 10-30 min, Mech: reduction in CO (through contractility and HR), IND: Acute aortic dissection, perioperative HTN, CON: Asthma, CHF, cocaine or amphetamine toxicity bradycardia
5) Hydralazine
Vasodilator, IV/IM (bolus), Onset: 10-20 min IV, 20-30 min IM, Duration: 2-6 hours, Mech: direct arterial vasodilator, IND: No IV access, IM bolus dosing, preeclampsia, CON: Heart disease, may overshoot desired BP due to bolus dosing
6) Fenoldopam
Dopamine D1 receptor agonist, IV, Onset 5-20min, Duration: 30-60 min, Mech: Increases renal blood flow/natriuresis and U/O, IND: Acute renal failure, sympathetic crisis, perioperative HTN, CON: anaphylaxis in patients with sulfate sensitivity, glaucoma
7) Phentoalamine
Alpha adrenergic blocker, IV, Onset: 5-10 min, Duration: 30-60 min, Mech: antagonism of circulating epinephrine and NE, ionotropic and chronotropic effects on heart, IND: Pheochromocytoma, cocaine, pseudophedrine toxicity, COn: MI or CAD
What BP abnormalities do you see in CoA?
Lower BP in the legs than the arms
Normally BP is higher in the legs than the arms
What disorder are you worried about in a patient with HTN and purpuric rash on the lower extremities?
HSP
