Hypertensive crisis

Hypertensive crisis (HC) is a state characterized by a sharp and significant increase in blood pressure, accompanied by clinical symptoms of functional disorder of vitally important organs (cerebral circulation, left-ventricular insufficiency, vegetative reactions) and requires urgent decrease in pressure.

In children, there are two types of hypertensive crisis:

symptoms of damage/lesions from target organs (CNS, heart, kidneys);
manifestations of sympatho-adrenal paroxysm with violent vegetative state.

The main reasons for the development of HC in children:

renal diseases (glomerulonephritis, hemolytic-uremic syndrome, tumors, injuries, etc.);
neurogenic pathology (intracranial hypertension on the background of toxicosis, intracranial injury, tumor, meningitis or meningoencephalitis);
vascular diseases (coarctation of the aorta, abnormalities of the renal arteries, vasculitis);
systemic diseases of connective tissue;
endocrine diseases (pheochromocytoma, hyperthyroidism, hyperparathyroidism, Cushing's syndrome, etc.);
primary arterial hypertension;
neuroses, psychogenic and neurovegetative disorders.

Diagnostic criteria:

sudden violation of the general condition of the child;
severe headache mainly in the temporal-frontal and occipital areas, heaviness in the occipital region, pulsation in the temples;
possible dizziness;
visual impairment (blurred vision, floaters, loss of vision, diplopia) or hearing (tinnitus), possible visual and auditory hallucinations; objectively – a violation of the eyeballs movement; during ophthalmoscopy – narrowing of the arteries and veins of the retina, the presence of exudates, edema of the optic disc, hemorrhage on the fundus;
nausea, vomiting that is not related to food intake and does not bring relief;
paleness or redness of the face, a feeling of blood flow to the face, cold sweat;
weakness or irritability;
altered mentation, paresthesia, paresis, hand tremor, feelings of fear and anxiety;
possible cardialgia, chest discomfort, dyspnea, intense pulse, tachycardia;
blood pressure is high, exceeds the 99th percentile.

Table. The following values of BP are typical of a hypertensive crisis:

For children under 1 year: systolic BP (SBP) > 120 mm Hg,

diastolic BP (DBP) > 85 mm Hg

For children 1-9 years: SBP > 130 mm Hg, DBP > 80 mm Hg

For children 10-12 years: SBP > 135 mm Hg, DBP > 90 mm Hg

For children older than 12 years: SBP > 145 mm Hg, DBP > 90 mm Hg

On the rise of the attack, the heart tones are amplified, further weakened, a third tone appears at the apex of the heart, the accent of the second tone appears or increases above the aorta, a systolic murmur is heard at the apex of the heart and aorta. Against the background of a hypertensive crisis, severe heart rhythm disorders and signs of heart failure may occur.

The ECG makes it possible to verify arrhythmia, signs of ischemia, myocardial hypertrophy, overload mainly of the left heart. Significant diagnostic tests in hypertensive crisis are X-ray examination of the abdominal cavity and echocardiographic examination, assessment of renal and neurological status.

Depending on the presence or absence of damage to target organs, there are: complicated and uncomplicated crises.

Figure. Red flags of hypertension

The principal goal of management is to gradually reduce BP and prevent end-organ dysfunction. In children and adolescents diagnosed with hypertensive crisis, the treatment goal with non-pharmacologic and pharmacologic therapy should be a reduction in SBP and DBP to <90th percentile and <130/80 mm Hg in adolescents ≥13 years of age. The rate of BP reduction should be 25% over a period of 6–8 h, which is gradually reduced to normal over 24–72 h since sudden, drastic reductions in blood pressure can itself contribute to organ damage secondary to ischemia.

Figure . Management outline for hypertensive crisis

Emergency care for uncomplicated HC

Position of the patient – on his back with his head raised.
Release the patient from tight clothing, ensure permeability of the upper respiratory tract.
Provide access to fresh air, if necessary – oxygen support.
At uncomplicated crisis, antihypertensive drugs are administered sublingually/orally.

Reassure the patient. At excitement and the expressed neurovegetative symptomatology injection of diazepam (seduxen, relanium, sibazon) of 0.2-0.3 mg/kg of body weight of 0.5% of solution intramuscularly (IM) or intravenously (IV) on 10% solution of glucose is possible.

In the initial therapy of HC ACE inhibitors are used, for example, captoprilum begins to act after 15 minutes (due to the rapid absorption in the stomach), and the peak of action occurs after 30-40 minutes after admission. Doses: up to 2 years 0.01-1 mg/kg/day orally, repeated doses after 8 hours; older than 2 years from 0.5 to 6 mg/kg of weight a day orally or sublingually in 8 hours.

Contraindications to the prescription of captoprilum: stenosis of the renal arteries, aorta, primary hyperaldosteronism.

Enalapril – dose 0.08-0.6 mg/kg/day, interval after 12-24 hours. Onset of action after 15-30 minutes, duration of action – 6 hours.

In cases of uncomplicated HC older than 14 years, the initial use of a class II calcium antagonist – nifedipine sublingually at a dose of 10-20 mg is effective. The drug reduces the total peripheral resistance, increases cardiac output and renal blood flow. Onset of action in 15-30 minutes.

In cases of HC with tachycardia, beta-blockers are appropriate – propranolol (1-4 mg/kg/day orally, after 6-12 hours). Contraindications –bradycardia, bronchoconstriction. Onset of action after 30-60 minutes.

It is possible to prescribe cardioselective beta-blockers – atenolol (0.5-2 mg/kg/day in 1-2 doses) or metoprolol (1-6 mg/kg/day in 1 dose). Children of early puberty should be restricted to prescribing due to the effect on the central regulatory structures involved in puberty.

In cases of aggravating anamnesis with uncomplicated HC, furosemide is used at a dose of 1-2 mg/kg IM, daily dose up to 6 mg/kg, interval of repeated injections is 4-12 hours.

As an additional means, IV administration of 25% solution of magnesium sulfate at a dose of 0.2 ml/kg (IV bolus), seldom 2% of euphyllin 1-3 mg/kg (IV bolus), in saline.

Emergency care for complicated HC

Urgent hospitalization.
Ensure permeability of the upper respiratory tract, if necessary, adjust ventilation, oxygen supply.
The method of administration of drugs is mainly IV.
If it is not possible to perform an IV infusion immediately before it is started, you can use sublingual or orally of one of the following drugs: older than 14 years sublingually nifedipine at a dose of 10-20 mg; captoprilum older than 2 years 0.5-1.0 mg/kg body weight; propranolol 1-2 mg/kg, clonidine – 0.002-0.03 mg/kg/day (mostly in adolescence).
Intramuscular injection of furosemide is possible.
Intravenous administration ("step-by-step", depending on the effectiveness of the previous drug):

ü Furosemide at a dose of 1-2 mg/kg, daily dose up to 6 mg/kg body weight, interval of administration 4-12 hours.

ü Selective blocker of calcium channels of the I class – verapamil 2-10 mg/kg/days; with HC on the background of arrhythmogenic cardiac syndrome; but do not use in patients with heart failure and those treated with beta-blockers.

ü Enalapril 0.08-0.6 mg/kg body weight per day, mainly in adolescence (effective in acute left ventricular failure).

At convulsions, eclampsia 25% solution of magnesium sulfate from 0.2 ml/kg to bolus doses – 5-20 ml slowly.

In the absence of effect – clonidine 0.01% solution (selective agonist of postsynaptic α2-adrenoreceptors of adrenergic neurons) – IM or subcutaneously, at a dose of 0.3-0.5-1.0 ml. IV administration in the same doses per 10-20 ml of 0.9% sodium hydrochloride solution slowly for 5-7-10 minutes, if necessary – drip (at a rate of 20 drops per minute).

In case of vegetative disorders use sedatives orally or IM/IV injections diazepam (seduxen, relanium, sibazon) at a dose of up to 0.2–03 mg/kg.

In case of HC complication by stroke, transient ischemic attack, emergency care begins with the injection of enalapril 0.625-1.25 mg.

In acute coronary syndrome, nitroglycerin is administered intravenously at 2–10 mg/min, dropwise or in aerosol 0.4–0.8 mg by inhalation; enalapril 0.625-1.25 mg, morphine 10 mg intravenously.

In case of pulmonary edema, it is advisable to provide emergency care to begin with the introduction of: enalapril 0.625-1.25 mg IV; nitroglycerin IV 2-10 mg/min in drop or in aerosol 0.4-0.8 mg by inhalation; morphine 10 mg intravenously; furasemide 20-100 mg IV.

With a dissecting aortic aneurysm: propranolol 1-3 mg or verapamil 5 mg IV slowly; then – nitroglycerin IV 2-10 mg/min drip; morphine – 10 mg IV.

In eclampsia, preeclampsia: cormagnesin 10% or 20% (magnesium sulfate) 1000-2500 mg IV slowly for 7-10 minutes.

In the presence of pheochromocytoma, the alpha₁-adrenoblocker prazosin 0.005–0.5 mg/kg/day is available (repeated administration in 6-8 hours).

Table . Characteristics of medications for management of hypertensive crisis