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RESEARCH ARTICLE

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First-attackpediatrichypertensivecrisispresenting tothepediatricemergencydepartment
1 2 1 3 4 5,6* Wen-ChiehYang ,Lu-LuZhao ,Chun-YuChen ,Yung-KangWu ,Yu-JunChang andHan-PingWu

Background: Hypertensivecrisisinchildrenisarelativelyrareconditionpresentingwithelevatedbloodpressure (BP)andrelatedsymptoms,anditispotentiallylife-threatening.Theaimofthisstudywastosurveychildrenwith firstattacksofhypertensivecrisisarrivingattheemergencydepartment(ED),andtodeterminetherelated parametersthatpredictedtheseverityofhypertensivecrisisinchildrenbyagegroup. Methods: Thiswasaretrospectivestudyconductedfrom2000to2007inpediatricpatientsaged18yearsand youngerwithadiagnosisofhypertensivecrisisattheED.Allpatientsweredividedintofouragegroups(infants, preschoolage,elementaryschoolage,andadolescents),andtwoseveritygroups(hypertensiveurgencyand hypertensiveemergency).BPlevels,etiology,severity,andclinicalmanifestationswereanalyzedbyagegroupand comparedbetweenthehypertensiveemergencyandhypertensiveurgencygroups. Results: Themeansystolic/diastolicBPinthehypertensivecrisispatientswas161/102mmHg.Themajorcausesof hypertensivecrisiswereessentialhypertension,renaldisordersandendocrine/metabolicdisorders.Halfofall patientshadasingleunderlyingcause,and8hadacombinationofunderlyingcauses.Headachewasthemost commonsymptom(54.5%),followedbydizziness(45.5%),nausea/vomiting(36.4%)andchestpain(29.1%).Afamily historyofhypertensionwasasignificantpredictivefactorfortheolderpatientswithhypertensivecrisis.Clinical manifestationsandseverityshowedapositivecorrelationwithage.IncontrasttodiastolicBP,systolicBPshoweda significanttrendintheolderchildren. Conclusions: Primarycliniciansshouldpayattentiontothepediatricpatientswhopresentwithelevatedblood pressureandrelatedclinicalhypertensivesymptoms,especiallyheadache,nausea/vomiting,andaltered consciousnesswhichmayindicatethatappropriateandimmediateantihypertensivemedicationsarenecessaryto preventfurtherdamage. Keywords: Hypertensivecrisis,Children,Hypertensiveurgency,Hypertensiveemergency of target-organs (heart, brain, kidneys and arteries), and Background It has been demonstrated that high blood pressure is (BP) a potentially life-threatening condition. Hypertensive contributes to the early development of cardiovascular encephalopathy, an example of hypertensive emergency, with hypertension (HTN) and includes a structural and functional changes in children [ 1 , is 2 associated ]. With increasingly high BP, autoregulation eventually fails, combination of various neurological manifestations such leadingtodamageofthe vascularwallandfurtherorgan asalteredmentalstatus,headache,nausea,vomiting,visual disturbance, seizure (76% of patients exhibit three of hypoperfusion. Hypertensive crisis is a critical condition characterized by a rapid, inappropriate and symptomatic thesefoursigns),orevenstroke[ 3 - 7 ]. elevated BP, and is categorized as hypertensive urgency The causes of HTN and hypertensive crisis vary by (without damage of target-organs) and hypertensive age. Primary HTN accounts for most hypertensive emergency, which is associated with rapid deterioration children over the age of six years,and 90% of the causes of HTN in childrenover15years of age[ 8 - 11 ]. Younger * Correspondence: arthur1226@gmail.com and more severe HTN pediatric patients are believed to 5 DepartmentofPediatrics,BuddhistTzu-ChiGeneralHospital,Taichung Branch,No.66,Sec.1,FongsingRd.,TanzihTownship,Taichung42743, account for secondary HTN. As a result of increasing Taiwan mean BMI levels and increasingsalt intake, the 6 DepartmentofMedicine,TzuChiUniversity,Hualien,Taiwan incidence of HTN in children appears to be steadily Fulllistofauthorinformationisavailableattheendofthearticle
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climbing [ 8 , 9 , 12 ]. The incidence of HTN in 2003 betweentheolecranonandtheacromion.The was cuff bladreported to range from 1% to 5% of children aged der 1 to length covered 80 to 100% of the circumference of 18 years in the United States [ 1 , 2 , 10 ]. In Taiwan, the HTN arm. Initially, aneroid manometers (automatic has been found to range from 0.13% to 0.5% of children devices) were used to measure BP with an appropriate aged 6 to 15 years, and around 1% to 3% of school-aged cuff. If the systolic BP (SBP) or diastolic BP (DBP) was children [ 13 , 14 ]. The objective of this study was higher to than 120/80 mmHg, it was re-measured from analyze the clinical features, etiology and treatment both ofhands and legs [ 15 ]. BP measurements were perchildren with first attacks of hypertensive crisis and formed to every hour in the patients who presented with determine the predictors of severity of hypertensive an unstable BP and in the patients requiring further obcrisis. servation. During the study period, the BP measurements were performed by different nurses, all of whom werewell-trainedandqualified. Methods
Patientpopulation

Identificationofhypertension From January 2000 to January 2008, we conducted this retrospective chart review of all patients 18 yearsHTN and in children more than 12 months of age was under with a diagnosis of HTN in our pediatric ED defined of according to BP standards based on gender, age ChanghuaChristian Hospital,a2500-bed medicalcenter and height as stipulated in the updated classification of incentralTaiwan.Theexclusioncriteriawereasfollows: hypertension by the National Blood Pressure Education th a BP below the 95 percentile, a final diagnosis of tranProgram Working Group on Hypertension in Children sient hypertension, asymptomatic hypertensive patients, and Adolescents [ 7 ]. HTN was identified when the SBP th and those with incomplete data including inadequate or DBP was greater than or equal to the percentile; 95 body height or weight data, and no repeated BP meastage 1 HTN was defined as an SBP or DBP within the th th surements. A total of 112 patients presented to our range of the 95percentile to the 99 percentile plus pediatric ED with the diagnosis of primary and second5 mmHg; stage 2 HTN was an SBP or DBP greater than th ary hypertension. Sixteen patients were excludedthe for 99 percentile plus 5 mmHg. For the patients th having a BP less than the 95 percentile, 28 were younger than 12 months of age, hypertension was th excludedfor asymptomatic hypertension, 10 were defined as an SBP or DBPgreater than the percent95 excluded due to a final diagnosis of transient hypertenile for infants of a similar age, size and sex according to sion, and three were excluded due to inadequate a data. previously published report [ 16 ]. When systolic and Therefore, the study group comprised 55 patientsdiastolic with percentiles differed, they were categorized hypertensive crisis. The study was approved by the according to the higher value. Transient HTN means HumanSubjectsReviewCommitteeofthehospital. transient blood pressure elevation caused by any emoThepatientsweredividedintofouragegroups:infants tional,painful,oruncomfortableevents,andwasdefined th (less than one year of age); preschool age (one to as six an asymptomatic BP higher than the percentile 95 th years of age); elementary school age (seven to 12 only years once or twice, but returning to less than the 95 of age); and adolescents (13 to 18 years of age). Patients percentile on the second or third measurement without with hypertensive crisis were furthersubcategorized anyantihypertensivemedication[ into 5 ]. two severity groups: hypertensive urgency and hypertenA hypertensive emergency was defined as HTN in the sive emergency. Severity was based on the presence presence of of acute or ongoing target-organ lesions, or end organ damage. Staging of HTN was defined as HTNinrelationtoanimmediatelife-threateningeventrea BP th th between the 95 percentile and 99 percentile plus quiringimmediateinterventiontoreducetheBP[ 9 , 11 , 13 ]. th 5 mmHg (stage 1) and above the 99 percentile plus HypertensiveurgencywasdefinedasanelevationinSBP/ th 5 mmHg(stage2). DBP higher than the 99 percentile plus 5 mmHg with any complication related to the HTN and no evidence of Bloodpressuremeasurements target-organ lesions. End organ damage was defined as All children above three years of age received initial impairmentinrenal,myocardial,hepatic,andhematologic BP measurements at our pediatric ED when triaging. functions, With and neurological manifestations derived from the exception of children who were bedridden and HTN.Acute (transient)end organ damage resulting from infants who wereunableto sit,BP was checked with HTN the was identified by abnormal clinical and laboratory children in a seated position with their backs supported, findingswhichsubsidedafteradecreaseinBP.Abnormal feet on the floor, right arm supported, and with the data cu-included abnormal electrocardiography findings, bital fossa at heart level. An appropriate cuff size impairedrenalfunctiontests,elevatedliverfunctionmarwas used with an inflatable bladder width that was at kers, least and neurological manifestations such as headache, 40% of the arm circumference at a point midway alteredconsciousnessanddizziness.

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Hypertensive encephalopathy is a specific clinicalCase syn- distributions of hypertensive emergency and urdrome characterized by acute neurological change gency in the were surveyed based on different time periods. setting of sudden and/or prolonged HTN that overcomes During the study period, the BP levels,etiology, severity, the autoregulatory capacity of the cerebral vasculature and clinical manifestations were compared among chil[ 17 , 18 ].Thesyndromeisdefinedasseverehypertensionin dren by age group and compared between the patients conjunction with symptoms of headache, altered mental withhypertensiveemergencyandhypertensiveurgency. status,seizure,or visualdisturbances,andcommonlypreStatisticalanalysis sents with reversible posterior leukoencephalopathy seen s onT2-weightedbrainmagneticresonanceimages[ 19 All - statistical 22 ]. analyses were performed using Fisher exact test, the Kruskal Wallis test, Jonckheere Terpstra Methodsofanalysis test, and chi-square test as appropriate. The results of The following data were collected and analyzed: age, the descriptive analyses of independent variables were gender,weight,height,familyhistoryofHTN,BPonarrival reported as percentages and meanS.D. A P value less to the ED, clinical manifestations of hypertensive crisis than0.05wasconsideredstatisticallysignificant.Statistical (dizziness, headache, nausea/vomiting, visual symptoms, analyses were performed using SPSS software (version seizure/type, altered consciousness, chest tightness/pain, 15 .0 ;SPSSInc.,Chicago,IL,USA). target-organdamage),reversibility,anti-hypertensiondrugs, underlying causes (renal disease, cardiovascular (CV), Results Characteristicsofthestudysubjects essentialHTN,centralnervoussystem(CNS)factors,endocrine/metabolic disorders, oncological disease), recurrent From2000to200755childrenpresentedtotheEDwith episodes, brain imaging and duration of hospitalization hypertensive crisis, including 46 cases (83.6%) with (ward/intensive care unit (ICU)). In addition, to decrease hypertensive urgency and9cases(16.4%)withhypertenthe influence of age, exact BMI percentile and z-score sive emergency (incidence ratio 5:1). Five children had a (standarddeviationscore),andSBP/DBPz-scoreaccording diagnosis of hypertensive encephalopathy. The male-toto the Center for Disease Control (CDC) growth charts female incidence ratio was 5:1 (boys, n=46; girls, n=9). werealsoanalyzed. Most patients were in the adolescent group (n=24, CNS factors referred to CNS abnormalities as the 43.6%). A family history of hypertension was only noted cause of hypertension, which is different from hypertenin the patients older than preschool age (n=8, 14.5%). sive encephalopathy in causal connection. Essential Almost all of the pediatric hypertensive crisis patients hypertension was diagnosed after excluding secondary presented with hypertension stage 2 (n=54, 98.1%). The causesof hypertensionbymultipletests,suchaselectromajor symptoms of hypertensive crisis were headache cardiography, metabolic panel, renal function tests, (n=30, 54.5%), followed by dizziness (n=25, 45.5%), hemoglobin and urine routine tests, or other further and nausea/vomiting (n=20, 36.4%) (Figure 1 ). The specific tests including echocardiography, renal ultraleading underlying causes were essential hypertension sound, plasmarennin activity,plasmaaldosterone, (n=26, 47.2%), followed by renal disease, and endothyroid-stimulating hormone and 24-hour urine free crine/metabolic disease. The renal diseases included cortisol. nephrotic syndrome (n=2, 14.3%), IgA nephropathy

Figure1 Ratiosofclinicalmanifestationsinthepediatricpatientswithhypertensivecrisis.

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Table1Characteristicsofthepatientswithhypertensivecrisisbyagegroup
<1(n=7) Variables Gender Female Male Familyhistory BloodPressure SBP>99thpercentile+5 DBP>99thpercentile+5 Stageofhypertension Stage1 Stage2 Clinicalpresentations AlteredConsciousness Headache Nausea/Vomiting Visualsymptoms Seizure Dizzy Chestpain End-organdamage Reversibility Anti -HTNdrugs Etiology EssentialHTN Renaldisease CNS Endocrine/metabolic CV Oncology Recurrentepisode Severity Urgency Emergency Hospitalization Ward ICU POU
1

16 (n=5) N 3 2 0 4 3 1 4 2 3 2 0 2 0 1 2 3 2 1 1 1 1 0 1 1 3 2 4 1 0 % 60.0 40.0 0.0 80.0 60.0 20.0 80.0 40.0 60.0 40.0 0.0 40.0 0.0 20.0 40.0 60.0 40.0 20.0 20.0 20.0 20.0 0.0 25.0 20.0 60.0 40.0 80.0 20.0 0.0

Age(years) 712(n=19) N 4 15 2 19 14 0 19 2 13 8 0 1 11 8 3 9 10 8 6 0 3 1 1 5 16 3 8 3 8 % 21.1 78.9 10.5 100.0 73.7 0.0 100.0 10.5 68.4 42.1 0.0 5.3 57.9 42.1 15.8 47.4 52.6 42.1 31.6 0.0 15.8 5.3 5.3 26.3 84.2 15.8 42.1 15.8 42.1

18(n=24) 13 N 2 22 6 24 19 0 24 3 14 8 2 2 12 7 2 13 16 15 4 1 4 0 0 6 22 2 9 3 12 % 8.3 91.7 25.0 100.0 79.2 0.0 100.0 12.5 58.3 33.3 8.3 8.3 50.0 29.2 8.3 54.2 66.7 62.5 16.7 4.1 16.7 0.0 0.0 25.0 91.7 8.3 37.5 12.5 50.0 0.425 0.271 1.000 0.398 0.886 0.565 0.068 0.085 0.922 0.693 0.142 0.094 0.195 0.178 0.931 0.285 0.008 0.423 0.202 0.952 0.252 0.092 0.440 0.178 0.372 0.054 0.960 0.201 0.282 0.130 0.187 0.086 0.701 0.054 0.001 0.166 0.120 0.358 0.117 0.389 0.196 0.086 0.362 0.091 0.779 0.108 0.049 0.282 0.955 0.313
1 P-value 2 P-value

N 0 7 0 7 6 0 7 2 0 2 0 1 2 0 2 3 2 0 3 2 1 1 0 4 5 2 3 0 4

% 0.0 100.0 0.0 100.0 85.7 0.0 100.0 28.6 0.0 28.6 0.0 14.3 28.6 0.0 28.6 42.9 28.6 0.0 42.9 28.6 14.3 14.3 0.0 57.1 71.4 28.6 42.9 0.0 57.1

0.037

0.517

sexacttest. byFisher 2 bythechi-squaretestfortrend. SBP:systolicbloodpressure;DBP:diastolicbloodpressure;HTN:hypertension;CNS:centralnervoussystems;CV:cardio-vascular;ICU:intensivecareunit;POU: pediatricobservationunit.

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(n=2, 14.3%),poststreptococcal glomerulonephritis HTN was also diagnosed in approximately half of the (n=1, 7.1%), end stage renal disease (ESRD), Henochpatients (n=26, 47.3%). Among the underlying causes, Schnleinpurpurawith glomerulonephritis (n=1,7.1%), essential HTN had a significant correlation with age ureteropelvic junction obstruction (n=1, 7.1%), Alport (Table 1 ).Thez-scoresofBMIandSBP/DBPinthechilsyndrome with ESRD (n=1, 7.1%), focal segmental dren by age group are listed in Table 2 . The mean BMI glomerulosclerosis with ESRD (n=1, 7.1%), polycystic values of the children with hypertensive crisis were all kidney (n=1, 7.1%), Alstrom syndrome with chronic above the threshold of obesity. The mean SBP/DBP in renal insufficiency (n=1, 7.1%), inborn error, hyperamthepatientswithhypertensivecrisiswas161/102mmHg. monemia with ESRD (n=1, 7.1%), ESRD s/p renal In contrast to DBP, SBP had a significant trend with transplantation (n=1, 7.1%),and SLE with lupus older age. The patients with hypertensive crisis received glomerulonephritis (n=1, 7.1%). The endocrine and antihypertensive agents, and the BP levels gradually metabolicdiseases included hyperthyroidism (n=3, decreased by about 25% to 30% within one hour, finally 33.3%), diabetesmellitus(n=3,33.3%),hyperaldosteronreturningtonormalranges about twotothreedays later ism (n=1, 11.1%), adrenal hyperplasia (n=1, 11.1%), duringhospitalization. and methylmalonic academia with hyperuricemia (n=1, Patientswithhypertensiveencephalopathy 11.1%).Theoncologicaldisordersincludedpheochromocytoma associated with neurofibromatosis (n=1, 50%) Five male patients, all without a family history of hyperand paraganglioneuroma (n=1, 50%). The recurrence tension, had hypertensive encephalopathy at the ages of rate of hypertensive crisis was 29.1% (16 cases: 12 5, 9, ur-12, 13 and 14 years, respectively (Table 3 ). Their gency; 4 emergency) during the study period. A total presentingBPlevelsattheEDwereallclassifiedasstage of 33(60%) patients who visited the ED were hospitalized: 2 hypertension, and four of them had a DBP and SBP th 24 to wards, 7 to the pediatric intensive care unitabove the 99 percentile plus 5 mmHg, ranging from (PICU),and2tothepediatricobservationunit(POU)of 148to 231 mmHg of systolic BP, and 86 to 172 mmHg thepediatricED. ofdiastolicBP.Allhadalteredconsciousness;threewere in a coma on arrival and recovered after their BP had Hypertensivecrisisbyagegroup been controlled. The major associated symptoms were Boys had a higher morbidity of hypertensive crisis headache in and nausea/vomiting. Oncological causes were every age group except for the infant group (Table the 1 major ). A factors in the patients with hypertensive enpositive family history was present only in the children cephalopathy, one being induced by pheochromocytoma older than 7 years: 2 (10.5%) in the school age group, and one by paraganglioneuroma. Two of the patients and 6 (25%) in the adolescent group. About half of with thehypertensive encephalopathy had recurrent hyperpatients had underlying causes (n=27, 49%). Essential tensive crisis episodes duringthe study period. Magnetic
Table2Descriptionofresultsobtainedinvariousagecategoriesofhypertensivecrisispatientsincharacteristics,BMI andbloodpressure
Age BW Height HeightZ-Score BMI BMIZ-score BMIPercentile SBP DBP ExpectedSBP ExpectedDBP SBPZ-score DBPZ-score 16(n=3)a MeanSD 27.67 20.43 103.00 15.72 8.85 2.91 24.30 12.95 1.52 1.68 81.33 20.74 189.67 36.91 136.00 38.16 103.80 16.23 76.78 22.76 8.10 4.15 5.22 5.26
b 712(n=13) c 18(n=18) 13

P-value 0.005 <0.001 <0.001 0.522 0.587 0.675 0.174 0.013 <0.001 <0.001 0.135 0.432

Posthoctests a,b<c a<b<c a<b<c

MeanSD 53.35 28.19 144.66 10.38 3.43 1.15 24.88 12.60 1.13 1.49 75.54 31.11 158.38 25.09 93.54 19.98 95.17 4.12 54.46 3.42 5.93 2.34 3.41 1.74

MeanSD 83.64 33.27 167.95 9.58 0.70 1.24 29.05 9.08 3.07 6.96 84.56 25.93 164.22 23.84 104.61 19.03 109.91 5.11 62.32 3.76 5.08 2.17 3.68 1.75

a>b b<c a>c>b

a,b,c:themeandataofeachagegroup. P-valuebyone-wayanalysisofvariancefollowedbySidakmultiplecomparisonsatatypeIerrorof0.05. SBP:systolicbloodpressure;DBP:diastolicbloodpressure;BMI:bodymassindex.

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Table3Thecharacteristicsofthepatientswithhypertensiveencephalopathy(N=5)
Case1 Gender(F/M) Age(year) Weight(kg) Height(cm) Familyhistory ArrivalBP Hypertensionstage SBP>99 percentile+5
th DBP>99 percentile+5 th

Case2 M 12 39 no 176/86 stage2 42 (31.4%)

Case3 M 13 68 158 no 220/128 stage2 82(59.4%) 34(36.1%)

Case4 M 5 19 110 no 231/172 stage2 106(84.8%) 86(101%) Drowsy + + 0 + 0 0 Nifedipine oncology Paraganglioneuroma 3 0 0 7(7/0/0)

Case5 M 14 35 no 148/109 stage2 3(2%) 12(11%) Disturbance + + 0 + + 0 captopril/ amlodipine Renaldisease >5 normal normal 6(6/0/0)

M 9 24 134 no 166/130 stage2 33(25.3%) 38(41.3%) Coma + 0 0 0 0 0

clinicalmanifestations Consciousnesschange Headache Nausea/Vomiting Visualsymptoms Seizure Dizzy Chesttightness Drugforanti-HTN Underlyingcauses Recurrentepisode(times) CSFdata EEGfinding Hospitalizationduration(days) (ward/ICU/POU) Coma 0 0 0 0 0 0 Coma + + + 0 0 0 Nifedipine, Labetalol 0 0 0 normal 5(3/2/0)

Labetalol,Furosemide Labetalol oncology Pheochromocytoma 0 0 0 9(4/5/0) 0 0 0 0 11(5/6/0)

SBP:systolicbloodpressure;DBP:diastolicbloodpressure;HTN:hypertension;CSF:cerebrospinalfluid;EEG:Electroencephalography;ICU:intensivecareunit;POU: pediatricobservationunit.

resonanceimaging(MRI)ofthebrain revealedincreased patients;nifedipineinfourpatients;carvedilol,inderoland signal intensity in the subcortical white matter and labetalol corwere used separately in three cases; and pentoxiticalgraymatteroftheparieto-occipitalarea,cerebellum fylline, servidipine, lisinopril, and nicametate were each and basal ganglia. Magnetic resonance spectrometry used once. None of the patients received antihypertensive (MRS) showed a high lactate peak with normal N-acetyl medicationbeforearrivingatthepediatricED. aspartate(NAA),cholineandcreatinelevels(Table 3 ).

Discussion In comparison to adults, hypertensive crisis in children The year and month distribution analysis of hypertensive is a relatively rare condition. It presents with elevated urgencyandemergencyisshowninFigure 2 .Theanalysis BPandrelatedsymptomsandispotentiallylife-threatenrevealedthattheprevalenceofchildrenwithhypertensive ing. In clinical practice, high BP is often treated as an crisisinthetotalnumberofchildrenwhocametotheED associated symptom rather than a specific complaint. increasedbyyearduringthestudyperiod.Thedistribution However, the importance of pediatric hypertension is by month revealed that hypertensive emergency easily occurred underestimated without understanding the dammostlyinthespring(MarchtoJune). agecausedbyhighBP. Duringthestudyperiod,therewerenocasesofmortality For the pediatric patients with hypertensive crisis in or sequelae. Nine patients received multi-antihypertensive our study, as their age increased, more related family agents. Long-term-acting amlodipine besylate washistoriesofHTNandmoreessentialhypertensive used in causes seven patients; atenolol in nine patients; captopril were in sixnoted. After seven years of age, essential HTN
Casedistributionanalysisandtreatment

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Figure2 Distributionofhypertensivecrisisinthechildrenfrom2000to2008byyear (A),andmonth(B).

became the major cause of first-attack hypertensive warning cri- signs of the end organ damage and secondary sis, whereas before the age of seven, hypertensive crisis hypertension. Other reported related symptoms of HTN wasmostlyattributed tosecondaryHTN.However,even in children include blurred vision, and disease-specific though secondary hypertension was the major cause symptoms for such as edema, pallor and petechiae [ 23 ]. In the younger patients, there was no statistical correlation addition, although the patients with hypertensive emerbetween age and different underlying causes of pediatric gency in the current study did not have any sequelae, hypertensivecrisis.Renaldiseaseswerethemajorunderpermanent neurological damage, blindness, and chronic lying cause of first-attack hypertensive crisis, andrenal they failure have been reported to be long-term consecould induce a first attack of hypertensive crisis at quencesof any hypertensiveemergency[ 24 ]. age. Catecholamine producing tumors, such as pheoThere are some limitations to our study. First, due to chromocytoma and paraganglioneuroma induced the higher relatively low incidence of hypertensive crisis, only blood pressure, resulting in the highest BP and most 55patients sewere identified over the eight-year period of vere clinical outcomes, and were able to induce firstthis study. The small sample size and the selection of attacksofhypertensiveemergencyandevenhypertensive participants from a single medical center limit the encephalopathyatanyage. generalizability of our results to the entire population of Almost all of the patients in this study presented patients with with hypertensive crisis. Second, family histories th BP levels higher than the 99 percentile plus 5 mmHg and physical examination findings are not easily identifith (stage 2 HTN). Therefore, the 99 percentile plus able in a retrospective study, and this may have led to 5 mmHg may serve asacritical thresholdfor ahigh missing risk data in the analysis. These limitations may have of hypertensivecrisisinchildren.Somestudieshavealso ledtobiasinanalyzingthefirstattacksofhypertensivecrisuggested that stage 2 hypertension requires prompt sisintheED. evaluation and treatment once the stage of HTN is persistent [ 1 , 6 ]. Moreover, symptoms such as headache and Conclusions nausea/vomiting associated with a BP level above In the conclusion, ED physicians should pay attention to all th 99 percentile plus 5 mmHg should be regarded as pediatric patients who present with an elevated BP and

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14. KlumbieneJ,SileikieneL,MilasauskieneZ,ZaborskisA,ShatchkuteA: The clinical symptoms including headache, nausea/vomiting, relationshipofchildhoodtoadultbloodpressure:longitudinalstudyof andaltered consciousness.Oncepatients have aBPlevel 538. juvenilehypertensioninLithuania. JHypertens 2000, 18: 531 higherthanstage2hypertension,appropriateandimme15. DinsdaleHB: Hypertensiveencephalopathy. NeurolClin 1983, 1: 316. 16. Clinicalanalysisofhypertensioninchildrenadmitted diate antihypertensive medications are necessary toYangWC,WuHP: pre47. totheemergencydepartment. PediatrNeonatol 2010, 51: 40 ventfurtherdamage.

17. PavlakisSG,FrankY,ChusidR: Hypertensiveencephalopathy,reversible occipitoparietalencephalopathy,orreversibleposterior Competinginterests leukoencephalopathy:threeNamesforanoldsyndrome. JChildNeurol Theauthorsdeclarethattheyhavenocompetinginterests. 281. 1999, 14: 277 18. PintoA,RoldanR,SollecitoTP: Hypertensioninchildren:anoverview. 440. JDentEduc 2006, 70: 434 contributions Authors 19. KentAL,KecskesZ,ShadboltB,FalkMC: Bloodpressureinthefirstyearof WCYandCYCreviewedthemedicalrecords,analyzedandinterpretedthe 1749. lifeinhealthyinfantsbornatterm. PediatrNephrol 2007, 22: 1743 data,anddraftedthemanuscript;LLZandYWinterpretedthedata,and 20. OppenheimerBS,FishbergAM: Hypertensiveencephalopathy. ArchIntern draftedthemanuscript.YJCanalyzedandinterpretedthedata.HPW 278. Med1928, 41: 264 designedandoversawthestudy,interpretedthedata,andrevisedthe 21. HincheyJ,ChavesC,AppignaniB,BreenJ,PaoL,WangA, etal: A manuscript.Allauthorshavereadandapprovedthemanuscriptfor reversibleposteriorleukoencephalopathysyndrome. NEnglJMed 1996, publication. 500. 334: 494 22. BakshiR,BatesVE,MechtlerLL,KinkelPR,KinkelWR: Occipitallobeseizures Authordetails 1 asthemajormanifestationofreversibleposteriorleukoencephalopathy DepartmentofPediatrics,ChanghuaChristianHospital,Changhua,Taiwan. 2 syndrome:magneticresonanceimagingfindings. Epilepsia 1998, DepartmentofPediatrics,BuddhistTzu-ChiGeneralHospital,TaipeiBranch, 3 299. 39: 295 Taichung,Taiwan. DepartmentofSurgery,BuddhistTzu-ChiGeneral 4 23. WuHP,YangWC,WuYK,ZhaoLL,ChenCY,FuYC: Clinicalsignificanceof Hospital,TaichungBranch,Taichung,Taiwan. LaboratoryofEpidemiology bloodpressureratiosinhypertensivecrisisinchildren. ArchDisChild andBiostastics,ChanghuaChristianHospital,Changhua,Taiwan. 5 205. 2012, 97: 200 DepartmentofPediatrics,BuddhistTzu-ChiGeneralHospital,Taichung Hypertensivecrisisinchildren. PediatrNephrol Branch,No.66,Sec.1,FongsingRd.,TanzihTownship,Taichung42743, 24. ChandarJ,ZillerueloG: 6 751. 2012, 27: 741 Taiwan. DepartmentofMedicine,TzuChiUniversity,Hualien,Taiwan. Received:2July2012Accepted:19December2012 Published:31December2012 doi:10.1186/1471-2431-12-200 Citethisarticleas: Yangetal. : First-attackpediatrichypertensivecrisis presentingtothepediatricemergencydepartment. BMCPediatrics 2012 12 :200.

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