Tăng huyết áp cấp cứu và khẩn cấp ở trẻ em .pdf

Tăng huyết áp cấp cứu-khẩn cấp ở trẻ em

1. TIẾP CẬN CHẨN ĐOÁN VÀ
ĐIỀU TRỊ TĂNG HUYẾT ÁP
CẤP CỨU-KHẨN CẤP
BS.NHỮ THU HÀ

2. INTRODUCTION
•THA nặng, cótriệuchứngkhôngthườngxảyraở trẻem, nhưngkhigặpthường
làcấpcứuđedọatínhmạng( life-threatening emergency)
•BS LS cầntiếpcậnvới1 tháiđộkhẩntrươngđểHA vàhạnchếviệctổnthương
cơquanđích, tránhđiềutrịquátíchcực( →thiếumáunãovàtổnthương
thêmdo điềutrị)
(Springer Nature Reference) Joseph T. Flynn (editor), Julie R. Ingelfinger (editor), Tammy M. Brady (editor) - Pediatric Hypertension-Springer (2023)

4. DEFINITION

5. Copyrights apply
TRA BẢNG

6. APP ?

7. Signs and symptoms of hypertensive crisis and
prevalence in children

8. Hypertensive Urgency vs. Emergency: What's the Difference?
Hypertensive
crisis
Hypertensive
emergencies
Hypertensive
urgencies

9. CASE CLINIC
•Bé gái 6 tuổi, nhập viện vì nhức đầu và mờ mắt 1 tuần, không sốt, không yếu liệt. Tiền căn :
Mẹ thấy bé xanh xao, ăn uống kém hơn 1 năm nay. Lúc nhỏ phát triển bình thường.
•Khám : tỉnh, mạch 100 lần/phút, mạch 2 tay rõ, không bắt được mạch 2 chân. Huyết áp 2
tay 160/100 mmHg, huyết áp 2 chân không đo được, SpO2 95% tứ chi. Tim đều, mỏm tim
ở KGS V đường nách trước trái, phổi không rale. Các cơ quan khác chưa phát hiện lạ.
•Chọn đáp án đúng & giải thích lựa chọn :
A.THA khẩn cấp
B. THA cấp cứu
C.THA ác tính
D.THA giai đoạn I
E.THA giai đoạn II

10. Hypertensive emergency
•As noted by the 2017 AAP guidelines, pediatric patients should be referred to an
immediate source of care (eg, emergency department) if they have serious
symptoms and the BP value is at the stage 2 level ,or the BP is >30 mm Hg above
the 95th percentile for children less than 13 years of age or >180/120 in an
adolescent [2].
• In the clinical setting of a hypertensive emergency, there is concern for acute
hypertensive end-organ damage that can be life-threatening

11. keep in mind
•However, it is important to note that the absolute degree of BP elevation is less
important than whether end-organ symptoms and/or damage are present and
associated with an acute change in mean arterial pressure. For example, a child with
chronic hypertension may have very high BP measurements with no symptoms.
Another child with an acute rise in BP may manifest a hypertensive emergency despite
a BP that is only moderately elevated.

12. Damage to organs in a hypertensive emergency ?
Nguồn bài giảng THA : BSCK2. Hoàng Quốc Tưởng

13. LÂM SÀNG ĐÁNH GIÁ NHANH TỔN THƯƠNG CƠ QUAN ĐÍCH ?
Brain Eyes KidneysHeart
Hypertensive emergencies in children most commonly manifest as hypertensive
encephalopathy: severe BP elevation with cerebral edema and neurological
symptoms of lethargy, coma, and/or seizures

14. Hypertensive urgency
•A severe elevation in BP without symptoms or evidence of acute target-organ
damage describes a hypertensive urgency. A child with hypertensive urgency
warrants an immediate evaluation. When the urgency arises from an acute
process with a rapid change in mean arterial pressure, intervention should occur
promptly, and treatment with IV antihypertensive medications is appropriate
However, in the setting of a chronic condition (eg, chronic kidney disease) where
BP has increased gradually over time, lowering of the BP should occur less quickly
(eg, hours to days).

15. Pathophysiology
Raina R, Mahajan Z, Sharma A, Chakraborty R, Mahajan S, Sethi SK, Kapur G, Kaelber D. Hypertensive
Crisis in Pediatric Patients: An Overview. Front Pediatr. 2020 Oct 20;8:588911. doi:
10.3389/fped.2020.588911. PMID: 33194923; PMCID: PMC7606848.

16. Etiologies of Severe Hypertension

17. Copyrights apply

18. INITIAL STABILIZATION
•Maintain airway, breathing, and circulation (ABC)
•Confirm elevated blood pressure
•Evaluate for target-organ damage
•Identify conditions that alter initial blood pressure management
•Treat hypertensive emergency or urgency

19. Confirm elevated blood pressure
“Simultaneous with supportive
measures”
Patients who newly present with acute
hypertension should also have BP
taken in all four limbs; lower extremity
BP that is less than upper extremity BP
or significant difference between right
and left upper extremity BP suggests
coarctation of the aorta

20. Signs of target-organ damage
Target-organ Signs
Central nervous
system (CNS)
CNS findings may include headache (most common complaint), altered mental status (lethargy,
coma, or confusion), seizures, and irritability (infants) [1,6,7,9]. When these symptoms are
associated with white matter edema on neuroimaging, patients should be considered to have
reversible posterior leukoencephalopathy syndrome (RPLS). Facial nerve palsy (most frequently
unilateral), vision change, and hemiplegia are other reported CNS findings in children with
hypertensive emergencies
Eye Funduscopic examination is of particular importance because papilledema and retinal hemorrhage
or exudates may be the only signs of a hypertensive emergency
Heart Heart failure secondary to a hypertensive emergency may have findings of left ventricular heart
failure (tachypnea, pulmonary edema, S3 or S4 gallop rhythm, and new or changed heart murmur)
Renal Hematuria and proteinuria may represent manifestations of glomerulonephritis, a common cause of
hypertensive emergency. Peripheral edema suggests fluid overload in association with renal disease.
Acute, severe hypertension can cause acute kidney injury.

21. Reversible posterior leukoencephalopathy syndrome (RPLS)
•Reversible posterior leukoencephalopathy syndrome (RPLS)，first described by
Hinchey et al[1] in 1996,is also known as posterior reversible encephalopathy
syndrome. RPLS is an underappreciated syndrome characterized by clinical
symptoms of headache, altered mental functioning, visual loss, and seizures, and
radiological findings by magnetic resonance imaging (MRI) of subcortical oedema
predominantly in the posterior cerebral white matter. In most cases both the
symptoms and radiological features of RPLS are reversible. The precise
pathophysiology of RPLS remains uncertain. Deficiency in cerebrovascular auto-
regulation is a favoured hypothesis because the syndrome is associated with
hypertensive encephalopathy.
Wang W, Zhao LR, Lin XQ, Feng F. Reversible posterior leukoencephalopathy syndrome induced by
bevacizumab plus chemotherapy in colorectal cancer. World J Gastroenterol. 2014 Jun 7;20(21):6691-7.
doi: 10.3748/wjg.v20.i21.6691. PMID: 24914397; PMCID: PMC4047361.

23. Identify conditions that alter initial blood pressure management
Prior to antihypertensive therapy, it is imperative to identify the
following patient populations
Patients for
whom rapid BP
lowering is
contraindicated
(Rapid lowering
of BP may
cause organ
ischemia)
Patients for
whom rapid BP
lowering is
contraindicated
(Rapid lowering
of BP may
cause organ
ischemia)
Patients who
require therapy
directed at the
underlying
cause
❖Patients with increased intracranial
pressure
❖Coarctation of the aorta
❖Severe pain that requires analgesia
❖Preeclampsia or eclampsia in
females during late pregnancy(
>34w)
❖Cocaine, amphetamine, or other
sympathomimetic overdose
❖Pheochromocytoma
❖Envenomation with sympathetic
hyperactivity

24. THA TRONG TĂNG ÁP LỰC NỘI SỌ ?
•ÁP lực CSF bình thường : 12-28 cmH2O ( 9-21 mmHg)
•ICP >20 mmHg ( 27 cmH20) kéo dài >5 phút kèm dấu hiệu hoặc triệu chứng thường
là ngưỡng điều trị.
•ICP = P
ss+ (I
formationx R
CSF)
•CPP = MAP –ICP
•BT ICP < 20 mmHg, MAP > 60-80 mmHg ( MAP =1.5x Age+55 mmHg), CPP bình
thường ở trẻ em ít nhất 40-60 mmHg
•Khi tăng ICP >20 mmHg →  MAP → duy trì áp lực tưới máu não (CPP)
•Cơ chế tự điều hòa đáp ứng với giảm CPP là tăng HA trung bình hệ thống và giãn
mạch máu não → Tăng V máu não → Tăng ICP thêm .

26. Copyrights apply
Initial management of hypertensive
emergencies in children and adolescents

27. Copyrights apply
Initial management of hypertensive
urgencies in children and adolescents

28. Copyrights apply

29. VẤN ĐỀ ?
Labetalol IV hoặc Hydralazine
IV/IM bolus ?
Nicardipine or labetalol truyền
liên tục ?
THỰC TẾ THỰC HÀNH ?

30. Copyrights apply

31. Antihypertensive treatment
8H 12-24H
Goal & Rate ?

32. KHUYẾN CÁO
•Mục tiêu : HATT ở bách phân vị 95 (trẻ
<13 tuổi ) và <130/80 ở trẻ ≥ 13 tuổi.
•Tốc độ hạ HA trong 8h đầu : 25%
(HATT đo được hiện tại của trẻ -HATT
mục tiêu)

33. Neonatal hypertension ?
• : ≥ 99
th
%tile
•Truyền liên tục : BN THA
nặng có triệu chứng
•Nicardipine là thuốc đk lựa
chọn cho nhóm này .
•1-12 tháng điều trị hạ áp cân
nhắc khi SBP ≥ 112 mmHg
or DBP ≥ 74 mmHg , chỉ định
khi SBP ≥ 118 mmHg or DBP
≥82 mmHg .
Pediatric_Emergency_Medicine 5th

34. Điều trị cá thể hóa trên 1 số nguyên nhân đặc biệt ?
Pediatric_Emergency_Medicine 5th

35. FURTHER EVALUATION
After initial stabilization and
treatment, further evaluation consists
of a complete history, physical
examination, and ancillary studies to
identify the underlying etiology.

36. Raina R, Mahajan Z, Sharma A, Chakraborty R, Mahajan S, Sethi SK, Kapur G, Kaelber D. Hypertensive
Crisis in Pediatric Patients: An Overview. Front Pediatr. 2020 Oct 20;8:588911. doi:
10.3389/fped.2020.588911. PMID: 33194923; PMCID: PMC7606848.