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Management of hypertensive emergencies and urgencies in children

Joseph T Flynn, MD, MS
Section Editors
George A Woodward, MD
F Bruder Stapleton, MD
Deputy Editor
James F Wiley, II, MD, MPH


Acute severe hypertension resulting in hypertensive emergencies and urgencies occurs infrequently in children. Proper management of this potentially life-threatening condition and prevention of its complications depend on prompt recognition and treatment.

The clinician should understand that there is a spectrum of severity of acute hypertension. Any classification scheme that divides the clinical presentation of acute severe hypertension into "urgent" or "emergent" is by its nature arbitrary [1,2]. Clinical findings, especially patient symptoms, must be used to gauge the severity of acute hypertension and guide management.

This topic discusses the rapid assessment and treatment of hypertensive emergencies and urgencies in children. The diagnostic evaluation to acute severe hypertension is discussed separately. (See "Approach to hypertensive emergencies and urgencies in children".)


Acute severe hypertension has traditionally been divided into hypertensive emergencies and hypertensive urgencies. The clinician should understand that there is a spectrum of severity of acute hypertension. Any classification scheme that divides the clinical presentation of acute severe hypertension into separate categories is by its nature arbitrary [1,2]. Clinical judgment must be used to gauge the severity of acute hypertension and guide management.

Hypertension — Hypertension in children is defined as either systolic and/or diastolic blood pressure (BP) ≥95th percentile measured upon three or more occasions. As in adults, hypertension in children is further divided into the two following stages:


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Literature review current through: Jul 2017. | This topic last updated: Mar 15, 2017.
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  1. Adelman RD, Coppo R, Dillon MJ. The emergency management of severe hypertension. Pediatr Nephrol 2000; 14:422.
  2. Flynn JT, Tullus K. Severe hypertension in children and adolescents: pathophysiology and treatment. Pediatr Nephrol 2009; 24:1101.
  3. Yang WC, Zhao LL, Chen CY, et al. First-attack pediatric hypertensive crisis presenting to the pediatric emergency department. BMC Pediatr 2012; 12:200.
  4. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289:2560.
  5. Flanigan JS, Vitberg D. Hypertensive emergency and severe hypertension: what to treat, who to treat, and how to treat. Med Clin North Am 2006; 90:439.
  6. Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet 2000; 356:411.
  7. Constantine E, Linakis J. The assessment and management of hypertensive emergencies and urgencies in children. Pediatr Emerg Care 2005; 21:391.
  8. Fenves AZ, Ram CV. Drug treatment of hypertensive urgencies and emergencies. Semin Nephrol 2005; 25:272.
  9. Varon J, Marik PE. Clinical review: the management of hypertensive crises. Crit Care 2003; 7:374.
  10. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004; 114:555.
  11. Welch WP, Yang W, Taylor-Zapata P, Flynn JT. Antihypertensive drug use by children: are the drugs labeled and indicated? J Clin Hypertens (Greenwich) 2012; 14:388.
  12. Temple ME, Nahata MC. Treatment of pediatric hypertension. Pharmacotherapy 2000; 20:140.
  13. Deal JE, Barratt TM, Dillon MJ. Management of hypertensive emergencies. Arch Dis Child 1992; 67:1089.
  14. Marik PE, Varon J. Hypertensive crises: challenges and management. Chest 2007; 131:1949.
  15. Hammer GB, Lewandowski A, Drover DR, et al. Safety and efficacy of sodium nitroprusside during prolonged infusion in pediatric patients. Pediatr Crit Care Med 2015; 16:397.
  16. Thomas CA, Moffett BS, Wagner JL, et al. Safety and efficacy of intravenous labetalol for hypertensive crisis in infants and small children. Pediatr Crit Care Med 2011; 12:28.
  17. Flynn JT, Bradford MC, Harvey EM. Intravenous Hydralazine in Hospitalized Children and Adolescents with Hypertension. J Pediatr 2016; 168:88.
  18. Tuncel M, Ram VC. Hypertensive emergencies. Etiology and management. Am J Cardiovasc Drugs 2003; 3:21.
  19. Hollander JE. Cocaine intoxication and hypertension. Ann Emerg Med 2008; 51:S18.
  20. Wells TG, Bunchman TE, Kearns GL. Treatment of neonatal hypertension with enalaprilat. J Pediatr 1990; 117:664.
  21. Spielberg DR, Barrett JS, Hammer GB, et al. Predictors of arterial blood pressure control during deliberate hypotension with sodium nitroprusside in children. Anesth Analg 2014; 119:867.
  22. Flynn JT. Safety of short-acting nifedipine in children with severe hypertension. Expert Opin Drug Saf 2003; 2:133.
  23. Sica DA. Centrally acting antihypertensive agents: an update. J Clin Hypertens (Greenwich) 2007; 9:399.
  24. Flynn JT, Pasko DA. Calcium channel blockers: pharmacology and place in therapy of pediatric hypertension. Pediatr Nephrol 2000; 15:302.
  25. Miyashita, Y, Peterson, D, Rees, JM, et al. Isradipine treatment of acute hypertension in hospitalized children and adolescents. J Clin Hypertens 2010; .
  26. Strife CF, Quinlan M, Waldo FB, et al. Minoxidil for control of acute blood pressure elevation in chronically hypertensive children. Pediatrics 1986; 78:861.
  27. Pancioli AM. Hypertension management in neurologic emergencies. Ann Emerg Med 2008; 51:S24.
  28. Vesey CJ, Cole PV. Blood cyanide and thiocyanate concentrations produced by long-term therapy with sodium nitroprusside. Br J Anaesth 1985; 57:148.
  29. Gouyon JB, Geneste B, Semama DS, et al. Intravenous nicardipine in hypertensive preterm infants. Arch Dis Child Fetal Neonatal Ed 1997; 76:F126.
  30. Milou C, Debuche-Benouachkou V, Semama DS, et al. Intravenous nicardipine as a first-line antihypertensive drug in neonates. Intensive Care Med 2000; 26:956.
  31. Dionne JM, Abitbol CL, Flynn JT. Hypertension in infancy: diagnosis, management and outcome. Pediatr Nephrol 2012; 27:17.
  32. Rocchini AP, Rosenthal A, Barger AC, et al. Pathogenesis of paradoxical hypertension after coarctation resection. Circulation 1976; 54:382.
  33. Will RJ, Walker OM, Traugott RC, Treasure RL. Sodium nitroprusside and propranolol therapy for management of postcoarctectomy hypertension. J Thorac Cardiovasc Surg 1978; 75:722.
  34. Rouine-Rapp K, Mello DM, Hanley FL, et al. Effect of enalaprilat on postoperative hypertension after surgical repair of coarctation of the aorta. Pediatr Crit Care Med 2003; 4:327.
  35. Nakagawa TA, Sartori SC, Morris A, Schneider DS. Intravenous nicardipine for treatment of postcoarctectomy hypertension in children. Pediatr Cardiol 2004; 25:26.
  36. Sibai BM, Mercer BM, Schiff E, Friedman SA. Aggressive versus expectant management of severe preeclampsia at 28 to 32 weeks' gestation: a randomized controlled trial. Am J Obstet Gynecol 1994; 171:818.
  37. Duley L, Henderson-Smart DJ, Meher S. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database Syst Rev 2006; :CD001449.
  38. Magee LA, Cham C, Waterman EJ, et al. Hydralazine for treatment of severe hypertension in pregnancy: meta-analysis. BMJ 2003; 327:955.
  39. Hanff LM, Vulto AG, Bartels PA, et al. Intravenous use of the calcium-channel blocker nicardipine as second-line treatment in severe, early-onset pre-eclamptic patients. J Hypertens 2005; 23:2319.
  40. Hoffman RS. Cocaine. In: Goldfrank's Toxicologic Emergencies, 8th, Goldfrank LR, Floembaum NE, Hoffman RS, Howland MA. (Eds), McGraw-Hill, Philadelphia 2006. p.1133.