Hypertensive crisis in children

A hypertensive crisis is a sudden increase in blood pressure that causes a significant deterioration in health and requires emergency care.

In children and adolescents, hypertensive crises mainly occur with secondary (symptomatic) arterial hypertension.

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Causes of secondary arterial hypertension

• Diseases of the kidneys and renal vessels (acute and chronic glomerulonephritis, pyelonephritis, stenosis and thrombosis of the renal arteries, renal hypoplasia, reflux nephropathy, hydronephrosis, Wilms' tumor, condition after kidney transplantation, etc.).
• Diseases of the heart and blood vessels (coarctation of the aorta, aortoarteritis, aortic valve insufficiency).
• Endocrine diseases (pheochromocytoma, hyperaldosteronism, hyperthyroidism, hyperparathyroidism, Cushing's syndrome, diencephalic syndrome).
• Diseases of the central nervous system (brain injury, intracranial hypertension).
• Taking medications (sympathomimetics, glucocorticosteroids, anabolic steroids, drugs (codeine, etc.)).

However, in older children and adolescents, a hypertensive crisis can also occur with primary arterial hypertension.

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Symptoms of hypertensive crisis

The clinical picture depends on the type of hypertensive crisis.

Hypertensive crisis type I. Characterized by a sudden increase in systolic (mainly), diastolic and pulse arterial pressure. In this case, neurovegetative and cardiac complaints predominate in children. They experience severe headaches, dizziness, nausea, sometimes vomiting, weakness. Children are excited and feel fear. Complaints of palpitations and pain in the heart area are typical. Red spots on the face and body, cold extremities, chills, tremors, sweating, deterioration of vision and hearing often occur. After the crisis, as a rule, a large amount of urine with a low specific gravity is excreted. Laboratory examination reveals leukocytosis in the blood, elevated serum glucose levels, signs of hypercoagulation, and proteinuria and hyaline casts in the urine. The duration of the attack is usually no more than 2-3 hours.

Hypertensive crisis type II develops more slowly. Patients experience a significant increase in systolic and especially diastolic blood pressure, while pulse pressure does not change or decreases. The clinical picture is dominated by changes in the central nervous system, the level of norepinephrine in the blood is elevated with normal glucose levels. The duration can range from several hours to several days.

Hypertensive crises can lead to complications that threaten the child’s life: hypertensive encephalopathy, cerebral edema, hemorrhagic or ischemic stroke, subarachnoid hemorrhage, pulmonary edema, acute renal failure, retinopathy, retinal hemorrhage.

Classification of hypertensive crises

• Type I - hyperkinetic (sympathoadrenal, neurovegetative).
• Type II - hypokinetic (norepinephrine, water-salt).

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Emergency care for hypertensive crisis

It is recommended to gradually reduce blood pressure to the upper limits of the age norm. During the first hour, systolic blood pressure is reduced by no more than 20-25% of the initial value, diastolic - by no more than 10%.

Children with hypertensive crisis are prescribed strict bed rest; frequent (every 10-15 minutes) determination of blood pressure, constant assessment of health; if necessary, an electrocardiogram is recorded. Treatment of hypertensive crisis depends on the presence of complications.

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Uncomplicated hypertensive crisis

• Hypertensive crisis type I. Its treatment, especially in the presence of tachycardia, should be started with the introduction of beta-blockers (atenolol is administered at a rate of 0.7-1.5 mg/kg x day), metoprolol - 3-5 mg/kg x day). Treatment can also be started with nifedipine, which is prescribed sublingually or orally at a dose of 0.25-0.5 mg/kg. If the effect is insufficient, clonidine can be used at a dose of 0.002 mg/kg sublingually or orally, captopril [1-2 mg/kg x day)] sublingually, 0.25% solution of droperidol (0.1 mg/kg) intravenously.
• Hypertensive crisis type II. First of all, nifedipine should be prescribed sublingually (0.25-0.5 mg/kg). Simultaneously with nifedipine, the fast-acting diuretic furosemide is prescribed at a rate of 1-2 mg/kg intravenously by jet stream. Following this, it is recommended to prescribe ACE inhibitors. In case of excitation, high activity of the sympathoadrenal system, the use of droperidol, diazepam (0.25-0.5 mg/kg) is justified.

Complicated hypertensive crisis

• Hypertensive encephalopathy, acute cerebrovascular accident, convulsive syndrome. In addition to nifedipine and furosemide, 0.01% clonidine solution is prescribed intramuscularly or intravenously, magnesium sulfate, diazepam. In addition, sodium nitroprusside can be administered intravenously by drip at a dose of 0.5-10 mg / kg x min) with a gradual increase
  or ganglion blockers can be used.
• Acute left ventricular failure. In hypertensive crisis with manifestations of acute left ventricular failure, emergency care is recommended to begin with intravenous administration of nitroglycerin [0.1-0.7 mcg/kg x min]], sodium nitroprusside (2-5 mcg/kg x min)] or hydralazine (0.2-0.5 mg/kg). In addition, furosemide is mandatory (especially in case of pulmonary edema). If the effect is insufficient, clonidine, droperidol, and diazepam are used.
• Pheochromocytoma. Catecholamine crises are stopped with alpha-adrenergic blockers. Phentolamine is diluted in 0.9% sodium chloride solution and administered intravenously very slowly at 0.5-1 mg every 5 minutes until blood pressure is normalized). Tropodifen is administered intravenously very slowly at 1-2 mg every 5 minutes until blood pressure is reduced).

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