 11 year old male, previously healthy, presenting

with chest pain after doing a flip on a trampoline,

over rotating, and landing his chest on his knees and
thighs
 Vitals
 BP 172/106 (197/143), HR 72, T 36.8, RR 22,
97%RA WT 42 kg, HT 159cm
 PE
 Tenderness to palpation over chest
WHAT DO YOU WANT TO
DO?
DIFFERENTIAL
Workup

• Normal CXR, no labs

DC

• Follow-up with cardiology

• 178/136
  Cardiology (6 days later)
 173/119
 ECG, ECHO, labs
 Ordered renal US w/ doppler, started
on Amlodipine 5mg, sent to
FOLLOW-UP nephrology
 Nephrology (2 days later)
 158/108
 UA normal
 Ordered CTA
• Based on age, height percentile, gender
• Measured manually, proper sized cuff, RUE
 Hypertension is sustained elevation of
systolic or diastolic BP at or above 95%ile
(Stage I between 95-99%ile, Stage II
>99%ile)
 Hypertensive Urgency
 Elevated BP without acute target organ
damage
 Hypertensive Emergency
 Elevated BP with acute target organ
damage (CV, CNS, kidneys)
 Hypertensive Encephalitis
 HA, emesis, temp change, vision change,
ataxia, AMS)
 Should have gotten:
 UA, Chem, CBC, +/- CXR, head CT, ECG
 When stable: Renal US with doppler,
complement C3, ANA, ECHO, renin,
aldosterone, TSH, tox screen
Cardiac – Coarctation, KD
Renal – SLE, RAS, renal parenchymal disease (reflux, PKD, AKI),
transplant, glomerulonephritis
Endocrine – Metabolic disorder, diabetes, obesity hyperthyroid or
hypothyroid, mineralcorticoid excess (hyperaldosteronism)
Onc – Wilms, pheochromocytoma
Other – White coat hypertension, steroids, stimulants, Williams,
essential, increased ICP, trauma, OSA, ingestions/toxins, NSAID
 5-10% of childhood hypertension
 Includes:
 Fibromuscular dysplasia, vasculitis (Takayasu’s, PAN), extrinsic
compression (tumor, trauma), syndromes (NF1, tuberous sclerosis,
Williams’, Marfans), other (radiation, UAC, trauma, transplant)
  Urgent: PICU -> Nicardipine,
labetolol drip, nitroprusside aim for
~ 25% reduction
 Medical: Antihypertensives
TREATMENT  Amlodipine (Ca channel blocker)
 Don’t use ACE or ARB initially if
unknown diagnosis
 Cause-specific Treatment
 • Labs – CBC, CMP, UA, thyroid studies,
Workup • Renal US with doppler, NO ECHO!

• If primary HTN -> ACE, ARB

Medication • If unknown -> Amlodipine

• Nephrology (secondary workup),

Referrals ophthomology
 Chronic, large vessel disease of unknown etiology

 Affects aorta and major branches

 Inflammation of vessel wall, with infiltration by T-cells, NK, plasma cells,

macrophages -> narrowing, fibrosis, aneurysm
 Presents with non-specific findings- malaise, weight loss, fever, htn,
abdominal pain
 Labs nonspecific – elevated ESR, CRP when active. Nee CTA!

 Later – diminished pulses, claudication, fibrosis, aneurysms, renal failure,

cardiac ischemia or failure, stroke
 Treatment includes steroids, MTX, other steroid sparing, angioplasty and
stents
 20% have monophasic course; 93% survival at 5 years