Initial management of hypertensive emergencies in children and adolescents

BP: blood pressure; IV: intravenous; BUN: blood urea nitrogen; ICP: intracranial pressure.
* Typically, BP is >30 mmHg above the 95^th percentile for age, sex, and height. The absolute level of BP elevation is less important than whether symptoms of end-organ damage are present. Auscultation is the preferred method during repeat measurement; appropriate cuff size and placement should be ensured. Refer to UpToDate content on pediatric hypertensive emergencies and normal BP in children.
¶ In addition to initial blood studies, all children with severe hypertension should undergo evaluation of a urinalysis with microscopy, electrocardiogram, echocardiogram, and chest radiograph; selected patients may warrant a urine toxicology screen or a urine pregnancy test. Obtaining these studies should not interfere with initial stabilization and treatment of a hypertensive emergency.
Δ Use automatic or auscultatory BP measurements until intra-arterial BP measurement can be obtained. Antihypertensive treatment should not be delayed to obtain intra-arterial access.
◊ Refer to UpToDate content on management of hypertensive urgencies in children and adolescents.
§ Refer to the UpToDate topics on evaluation of hypertensive emergencies and urgencies in children and adolescents.
¥ Refer to UpToDate content on treatment of increased intracranial pressure in children.
‡ The typical systolic BP goal is 95^th percentile for age, sex, and height.
† For patients with contraindications to labetalol, proceed to either continuous infusion of sodium nitroprusside or, in patients with chronic renal disease, IV bolus hydralazine. There is a wide range of dosing for continuous IV infusion of labetalol or nicardipine. In general, the clinician should start with the lowest dose of the range and adjust the infusion rate based upon BP response.
** Refer to UpToDate content on etiology of hypertension in children and adolescents.