Convulsions and hypertension in children: differentiating cause from effect

A diagnostic approach for the child with hypertension

Hypertension during childhood is not rare, with an estimated prevalence of between 1% and 2%, although it is often an underrecognized clinical entity. Elevated blood pressure may be a sign of underlying disease or it may represent early onset of essential hypertension. In recent years the measurement of blood pressure has been emphasized as an important component of the routine pediatric physical examination that enables early detection of children with hypertension. In the evaluation of the child with documented blood pressure elevation, confirmation of truly and persistently elevated blood pressure is of the utmost importance. In addition, a thorough history and a full clinical examination are essential. These are followed by appropriate investigations, which are tailored to the age of the child and to the severity of the blood pressure elevation. Investigations should not only focus on a search for the underlying cause, but also on establishing effects on target organs, complications or additional diseases and on assessment of the total cardiovascular risk to the individual patient. An algorithm, which is a valuable diagnostic tool for the diagnosis and management of the child with hypertension, is presented. All children with confirmed hypertension need long-term follow-up, counseling and treatment. In those cases where an underlying cause of the hypertension is detected, the established diagnosis then determines the specific therapy and management.

Subarachnoid hemorrhage and isolated atresia of the aortic arch

The case of a 14 year old boy with subarachnoid hemorrhage and atresia of the aorta without patent ductus arteriosus or intracardiac shunt is described. This case calls attention to the possibility of aortic obstruction in adolescents or young adults with hypertensive stroke. The clinical symptoms, radiographic findings, and surgical repair of isolated aortic interruption, including atresia, are discussed.

Status epilepticus in children and adults

Status epilepticus (SE) in children and adults is one of the most common neurology problems confronting the intensivist. Recognition of SE is usually straightforward, but may be complicated by the effects of other diseases or therapies. Emergent treatment is necessary to prevent further brain damage. This article reviews protocols for standard treatments of SE patients and includes recommendations for the management of refractory SE.

Hypertensive crisis in children

Children presenting with hypertension should be considered for emergency treatment when there is evidence of end-organ toxicity. Complications of extreme hypertension may be very serious, even life threatening, with the potential for life-long sequelae. Of greatest significance is damage to the central nervous system. Treatment of hypertensive emergencies should be directed toward the lowering of blood pressure enough to reduce toxicity, but not at a rate likely to cause hypoperfusion of vital organs. This blood pressure reduction should, in general, be carefully controlled in an intensive care unit, with attention to central nervous system, cardiac, and renal function. Intravenous agents are preferable under these circumstances, due to greater ease in modulating blood pressure. In the absence of specific contraindications, a continuous infusion of nicardipine or sodium nitroprusside is preferable. Intravenous labetalol by bolus injection, followed by continuous infusion, also may be used. Oral agents should be reserved for circumstances in which symptoms of end-organ toxicity are mild or absent. Since general pediatricians have limited experience with the treatment of hypertensive emergencies, consultation with physicians experienced in treating hypertensive emergencies is suggested when possible.