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HIGH-YIELD FACTS

  • If an initial oscillometric (automated) blood pressure measurement is abnormal, the initial measurement should be discarded and two additional oscillometric measurements obtained. If the average of these two measurements is ≥90th percentile for gender, age, and height, then the blood pressure should be measured twice using auscultatory technique with an appropriately sized cuff and these two values averaged to determine the patient’s blood pressure classification.

  • The funduscopic examination is the most frequently missed component of the evaluation of hypertensive patients.

  • The goals of evaluation and management for hypertensive patients in the emergency department are to classify the severity of hypertension, identify specific etiologies requiring unique treatments, identify contraindications to urgent initiation of antihypertensive medications, determine proper therapy, if needed, and disposition.

  • In pediatric hypertensive emergencies, blood pressure should be reduced by no more than 25% of the planned reduction over the first 8 hours of treatment.

The prevalence of pediatric hypertension has increased in recent decades. While still uncommon, pediatric hypertensive crisis is a potentially life-threatening condition and therefore requires physicians to have a thorough understanding of its presentation and management. There are numerous etiologies of hypertension to consider, but the goals of evaluation and management in the emergency department are to classify the severity of hypertension, identify specific etiologies requiring unique treatments, identify contraindications to urgent initiation of antihypertensive medications, determine proper therapy, if needed, and patient disposition.

DEFINITIONS

In 2004, The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents (Fourth Report) defined hypertension in patients 1 to 17 years old as an average systolic or diastolic blood pressure ≥95th percentile for gender, age, and height on three or more occasions taken over weeks to months, except in the presence of severe hypertension.1 In 2017, the Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents (Clinical Practice Guideline) provided new normative blood pressure tables based on normal-weight children and adolescents, excluding the overweight and obese individuals who were previously included in the derivation of the tables published in the Fourth Report.2 In addition, the Clinical Practice Guideline replaced the term “prehypertension” with “elevated blood pressure” and revised the criteria for stage 1 and stage 2 hypertension, as shown in Table 44-1. The normative blood pressure tables provide data to classify hypertension in children and adolescents 1 to 17 years old; unfortunately, such robust information is lacking for neonates and infants. In 2012, Dionne and colleagues used the limited published data in the literature to derive a reference table of estimated blood pressure values for neonates and infants more than 2 weeks old from 26 to 44 weeks postmenstrual age (Table 44-2).3 For infants beyond 44 weeks postmenstrual age until 12 months old, the percentile curves published in the Report of the Second Task Force on Blood Pressure Control in Children ...

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