In pediatrics, don't miss abnormal blood pressure
In pediatrics, don't miss abnormal blood pressure
The complex chart used to identify hypertension in children might be one reason why nearly 75% of cases of hypertension in children and adolescents go undiagnosed, according to David C. Kaelber, MD, PhD, MPH, chief medical informatics officer at The MetroHealth System in Cleveland.
To differentiate between normal and abnormal readings using a standard blood pressure chart, you need to remember not only the variety of blood pressure ranges, but also know the child's height percentile, in addition to their gender and age. This information can be difficult to verify, especially in the ED, says Kaelber. Kaelber and other researchers simplified the chart, focusing solely on a child's age and gender. This chart eliminates the need for a height percentile, and it reduces the number of values in the blood pressure table from 476 to just 64.1 (Editor's note: To obtain a copy of the simplified blood pressure chart, go to pediatrics.aappublications.org/cgi/content/full/123/6/e972. The document can be accessed for $12.)
"The table may be especially helpful for community EDs who do not see many pediatric patients, because they would have less experience interpreting blood pressures in children," says Kaelber. Although primary pediatric hypertension is a "silent" disease that won't appear to cause harm in the short term, Kaelber says "the real danger is that the primary hypertension will not be noticed and therefore go untreated for years or decades, with increasing morbidity and mortality in adulthood, primarily from coronary artery disease, strokes, and renal failure."
Checking blood pressure in the ED is especially important, he adds, "because, particularly for older children, the ED may serve as the source of primary care."
In addition, identifying a child with hypertension might be the first step in diagnosing another serious cardiac, renal, pulmonary, or endocrinological problem, says Kaelber.
Blood pressure measurements taken in children do not seem to be routinely interpreted to see if they are normal or abnormal, says Kaelber. "The whole goal of this simplified blood pressure screening table is to make it easier for someone interested in interpreting anyone's blood pressure to do so," he says. "This new table allows a nurse to easily look at any blood pressure, assuming they know the person's age and gender, and tell if the blood pressure is normal or abnormal."
Abnormal blood pressure can "certainly go undiagnosed by ED nurses, especially if they generally do not care for children, due to unfamiliarity with vital sign values of children," says Lori Shuler, RN, MS, CNP, nurse practitioner program manager for the Section of Emergency Medicine at Nationwide Children's Hospital in Columbus, OH. "It must be remembered that children are not just small adults," Shuler says.
Abnormal values could be caused by the stress of being in the ED. "The ED nurse needs to be careful not to just assume that the blood pressure is out of normal limits because of these extraneous events," says Shuler. "Also, be sure to use the appropriate size blood pressure cuff, as well as removing extra clothing from the extremity where the blood pressure is being taken. This will help ensure the most accurate reading."
Shuler says the most serious outcome that can occur in a child with undiagnosed increased blood pressure is end organ damage. "Effects that could be seen are heart and renal failure, retinopathy, seizures and stroke," says Shuler.
Reference
- Kaelber DC, Pickett F. Simple table to identify children and adolescents needing further evaluation of blood pressure. Pediatrics 2009; 123:e972-e974.
Sources
For more information on assessment of blood pressure in ED pediatric patients, contact:
- David C. Kaelber, MD, PhD, MPH, Chief Medical Informatics Officer, the MetroHealth System, Cleveland. Phone: (216) 778-2637. E-mail: [email protected].
- Lori Shuler, RN, MS, CNP, Nurse Practitioner Program Manager, Section of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH. Phone: (614) 722-4385. E-mail: [email protected].
Is a child's abnormal blood pressure 'real?' If a child's blood pressure indicates abnormal values, this might be due to your patient's anxiety over their ED visit. However, you need to ensure that these abnormal values aren't the cause of your patient's current symptoms. "One would want to be sure that the blood pressure is not a cause for the reason the patient is seeking care," says Lori Shuler, RN, MS, CNP, nurse practitioner program manager for the Section of Emergency Medicine at Nationwide Children's Hospital in Columbus, OH. "Some examples of this would be eye pain, headache, or hematuria." If a child presents to your ED with any of those three chief complaints and has elevated blood pressure, include this in your differential. "If a little one is screaming and crying and the blood pressure is elevated during the exam, and they have a headache, for example, you should consider that the cause of the headache is the blood pressure," says Shuler. "Consider that the blood pressure is real, until proven otherwise." |
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