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High Blood Pressure Emergencies in Children

(Acute Severe Hypertension)


Bruce A. Kaiser

, MD, Nemours/Alfred I. DuPont Hospital for Children

Reviewed/Revised Dec 2021 | Modified Sep 2022
Topic Resources

A hypertensive emergency is a particularly severe, sudden form of high blood pressure that can damage one or more vital organs.

  • Hypertensive emergencies occur when blood pressure rapidly increases.

  • In children, the first symptoms of a hypertensive emergency are typically a headache, listlessness, confusion, and seizures and, in infants, irritability.

  • Doctors diagnose hypertensive emergency by measuring blood pressure and doing tests for organ damage, such as electrocardiography, echocardiography, and blood and urine tests.

  • Treatment of hypertensive emergencies involves admitting children to an intensive care unit and giving drugs by vein to lower blood pressure as soon as possible.

When blood pressure is checked, two values are recorded. The higher value reflects the highest pressure in the arteries, which is reached when the heart contracts (during systole). The lower value reflects the lowest pressure in the arteries, which is reached just before the heart begins to contract again (during diastole). Blood pressure is written as systolic pressure/diastolic pressure—for example, 120/80 mm Hg (millimeters of mercury), referred to as 120 over 80.

A hypertensive emergency is a particularly severe, sudden form of high blood pressure. Diastolic blood pressure (the bottom number) is usually over 100 mm Hg, and there is evidence of progressive damage in one or more vital organs (typically the brain, heart, eyes, and kidneys). Children may have a variety of symptoms.

Hypertensive emergencies are relatively rare in children. They may develop in children who have or have not been previously diagnosed with high blood pressure.

Hypertensive emergencies usually occur when blood pressure rapidly increases. What causes the rapid increase varies by age. The most common causes are

A hypertensive emergency, if not treated promptly, typically causes progressive damage in one or more vital organs, particularly the following:

If untreated, a hypertensive emergency can be fatal.

A hypertensive urgency is severe high blood pressure that has not yet caused enough organ damage to result in symptoms.

Symptoms of Hypertensive Emergencies in Children

Blood pressure is very high, typically at a stage 2 (severe) high blood pressure level or higher (140/90 or higher).

In children, the first symptoms of a hypertensive emergency are typically a headache, listlessness (lethargy), confusion, seizures, and, in infants, irritability. Children may go into a coma.

Children may have a rapid heart rate, chest pain, shortness of breath, and/or swollen ankles. Vision may be impaired.

Diagnosis of Hypertensive Emergencies in Children

  • Blood pressure measurement

  • Tests to evaluate organ damage

During a suspected hypertensive emergency, doctors use an oscillometer to measure blood pressure Diagnosis High blood pressure (hypertension) is persistently high pressure in the arteries. Usually, high blood pressure in children, as in adults, has no identifiable cause. During childhood, most children... read more rather than using a stethoscope. The oscillometer records blood pressure automatically and quickly, which helps with the measuring that is needed (every 2 to 3 minutes). Blood pressure is measured again using a sphygmomanometer Measuring Blood Pressure Measuring Blood Pressure and a stethoscope to confirm the measurement. When possible, doctors do intra-arterial blood pressure monitoring, which involves putting a small plastic tube inside an artery and connecting it to a pressure monitor. These arterial pressure monitors measure blood pressure continuously and are also more accurate than other devices.

Tests are also done to determine whether vital organs are damaged and, if so, how much damage is present. Tests include

  • Electrocardiography (ECG), chest x-ray, and, if possible, an echocardiography to check for heart disorders

  • Urinalysis to screen for kidney abnormalities

  • Blood tests to check for kidney damage or hormonal abnormalities

  • Complete blood count to check for abnormal numbers of blood cells, particularly platelets (which help blood clot)

  • Computed tomography (CT) or magnetic resonance imaging (MRI) of the head to check for a mass or hemorrhage in the brain and to rule out other possible causes of symptoms related to the brain

  • Drug and pregnancy tests in adolescents

Treatment of Hypertensive Emergencies in Children

  • For hypertensive emergencies, admission to an intensive care unit and intravenous drugs to lower blood pressure

  • For hypertensive urgencies, admission to an emergency department or hospital and oral drugs to lower blood pressure (occasionally intravenous drugs are needed)

Children with a hypertensive emergency are rapidly admitted to an intensive care unit (ICU) Types of units People who need specific types of care while hospitalized may be put in special care units. Intensive care units (ICUs) are for people who are seriously ill. These people include those who have... read more or, if an ICU is not available, to an emergency department so that they can be quickly treated and evaluated and monitored closely. There, drugs to lower blood pressure (antihypertensive drugs) can be given by vein (intravenously) as soon as possible.

The goal of treatment of hypertensive emergencies is to lower blood pressure enough to eliminate the risk of life-threatening symptoms and to stop further damage to vital organs.

For hypertensive emergencies, the preferred intravenous drugs are labetalol and nicardipine.

If the preferred drugs cannot be used or do not work, sodium nitroprusside, hydralazine, and esmolol are other intravenous drugs that may be used.

Once blood pressure has been lowered, doctors can give children drugs by mouth (orally).

Children with a hypertensive urgency (severe hypertension but no symptoms and no organ problems) also are admitted to a hospital or emergency department and are evaluated immediately, but blood pressure does not need to be lowered as quickly as for a hypertensive emergency. These children are typically given drugs by mouth. Occasionally, intravenous drugs are needed.

For hypertensive urgencies, clonidine, hydralazine, isradipine, or minoxidil is given by mouth.

If possible, children with either disorder should be treated by a doctor or specialist experienced in managing severe high blood pressure in children.

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