Pediatric emergency medicine trisk 0756 0756
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In addition to treating the elevation in blood pressure levels, the child with
complications of hypertension may also require treatment of the specific
complications. Attention should always be paid to managing the child’s airway,
breathing, and circulation. The child with seizures or CHF often requires the
standard treatment of these problems in addition to antihypertensive therapy.
However, when other complications are believed to be secondary to severe
hypertension, treatment of the hypertension should take precedence.
SPECIFIC THERAPY
In a hypertensive emergency, adequate intravenous access should be secured
immediately, and the patient should have cardiorespiratory and blood pressure
monitoring. The intravenous route for medication administration is preferred for
most hypertensive emergencies, as this allows for more accurate titration of dose
to response. Absorption and effect of medications given enterally may be less
predictable, putting the patient at risk of relative hypotension. Management of
hypertensive emergencies by continuous IV infusion of a short-acting titratable
antihypertensive medication is ideal. The use of oral agents should be limited to
hypertensive urgencies only.
Although there is insufficient randomized controlled trial data to recommend a
specific drug protocol for hypertensive emergencies, the most commonly used
agents for hypertensive emergencies remain labetalol, nicardipine, and sodium
nitroprusside. Newer agents, such as clevidipine and fenoldopam, are gaining
favor based on their kinetic and safety profiles. Specific medications ( Table 37.4
) should be chosen based on their availability, the physician’s familiarity with the
drug, and the underlying pathophysiology of the hypertensive process. The sideeffect profile of each medication and drug–drug interactions must be taken into
account.
Intravenous Antihypertensive Medications
Labetalol
Labetalol is a combined α1 - and β-adrenergic blocking agent which has the
ability to reduce peripheral vascular resistance with little effect on heart rate or
cardiac output. It has a rapid onset of action (usually 5 to 10 minutes) and a
plasma half-life of 3 to 5 hours when given intravenously. Because of its duration
of action, labetalol can be more difficult to titrate to effect than other agents.
