Emergent Management of Subarachnoid

Updated: Sep 22, 2015

 Author: Rami C Zebian, MD; Chief Editor: Robert E O'Connor, MD, MPH more...

Emergent management of subarachnoid hemorrhage (SAH), including prehospital care, is
critical: An estimated 10-15% of patients die before reaching the hospital. Moreover,
mortality rate reaches as high as 40% within the first week, and about 50% die in the first 6
months. [1, 2, 3, 4, 5]

The common medical use of the term subarachnoid hemorrhage (SAH) refers to the
nontraumatic presence of blood within the subarachnoid space from some pathologic process,
usually from rupture of a berry aneurysm or arteriovenous malformation (AVM) (see the
following image).

Brain computed tomography (CT) scan
showing subtle finding of blood at the area of the circle of Willis consistent with acute
subarachnoid hemorrhage. Image courtesy of Dana Stearns, MD, Massachusetts General

emergency department (ED) care essentially is limited to diagnosis and supportive therapy. Prehospital care is critical and includes the following:  Address the patient's airway. Early identification of sentinel headaches is key to reduced mortality and morbidity rates. breathing. IV. as follows:  Grade I: Mild headache with or without meningeal irritation  Grade II: Severe headache and a nonfocal examination. Prehospital Care Advances in the management of subarachnoid hemorrhage (SAH) have resulted in a relative reduction in mortality rate that exceeds 25%. or V SAH . However. Arteriovenous Malformation. including mental status  Grade IV: Obviously depressed level of consciousness or focal deficit  Grade V: Patient either posturing or comatose See also Subarachnoid Hemorrhage. with or without mydriasis  Grade III: Mild alteration in neurologic examination.SAH classification Subarachnoid hemorrhage (SAH) is classified according to 5 grades. avoid sedating these patients en route Emergency Department Care Grade I or II SAH In patients with a suspected grade I or II subarachnoid hemorrhage (SAH). and Cerebral Aneurysms. and circulatory status (ABCs)  Triage and transport patients with altered level of consciousness or an abnormal neurologic examination to the closest medical center with a computed tomography (CT) scan and neurosurgical backup  Ideally. and closely monitor the patient's neurologic status. Mortality and morbidity rates increase with age and poorer overall health of the patient. more than one third of survivors have major neurologic deficits. Subarachnoid Hemorrhage Surgery. Secure intravenous access. Grade III. Use sedation judiciously.

Use rapid sequence intubation if possible. short-acting neuromuscular blockade. Consultations Obtain emergent neurosurgical consultation for definitive treatment of subarachnoid hemorrhage (SAH). avoid any increase in ICP due to excessive agitation from pain and discomfort. IV. defasciculation. Avoid excessive sedation. also decrease ICP without increasing serum osmolality  Intravenous steroid therapy to control brain edema is controversial and debated Provide supplemental oxygen for all patients with central nervous system (CNS) impairment. It should be used only in hypertensive patients because of its propensity to drop systolic blood pressure (SBP). and lasts 4 hours  Loop diuretics. In hypotensive and normotensive patients. However.In patients with a grade III. which is the leading cause of secondary brain injury. or V subarachnoid hemorrhage (SAH) (ie. ideally use sedation. . such as furosemide. which reduces ICP 50% in 30 minutes. It makes serial neurologic exams more difficult and has been reported to increase ICP directly. and other agents with ICP-blunting properties (such as intravenous lidocaine). In addition. Target the partial pressure of carbon dioxide (pCO2) at 30-35 mm Hg to reduce elevated ICP. Intubation Endotracheal (ET) intubation of obtunded patients protects them from aspiration caused by depressed airway protective reflexes. Precautions Avoid excessive or inadequate hyperventilation. peaks after 90 minutes. Address the patient's airway. to blunt intracranial pressure (ICP) increase. and circulatory status (ABCs). Thiopental and etomidate are the optimal induction agents in subarachnoid hemorrhage (SAH) during an intubation. altered neurologic examination). Use the following interventions early and judiciously to decrease elevated ICP when herniation is suspected:  Use osmotic agents. In the process. Also intubate to hyperventilate patients with signs of herniation. reliable neurologic examinations before and after initial treatment are critically important to optimizing management and to deciding on the appropriate neurosurgical intervention. Excessive hyperventilation may be harmful to areas of vasospasm. Thiopental is short-acting and has a barbiturate cytoprotective effect. use etomidate. breathing. such as mannitol. ED care is more extensive.

Interventional radiology may be needed when surgical intervention is deemed necessary by the neurosurgical consultant (eg. this avoids central nervous system (CNS) damage in the ischemic penumbra from the reactive vasospasm seen in subarachnoid hemorrhage (SAH). [6. and use cooling devices if necessary. then allow hypertension to keep the SBP less than 200 mm Hg. [8] Consider antiemetics for nausea or vomiting. Adjunctive Therapies and Measures Keep the patient's core body temperature at 37. End-tidal carbon dioxide monitoring of intubated patients enables the clinician to avoid excessive or inadequate hyperventilation. Consult critical care providers who will be involved in ongoing care of the patient. 9] . Maintain the patient's serum glucose level at 80-120 mg/dL. use sliding or continuous infusion of insulin if necessary. a large clot causing a mass effect is present and needs to be evacuated emergently). or pulmonary capillary wedge pressure [PCWP] of 12-16 mm Hg).2°C. Vasopressors may be indicated to keep the SBP over 120 mm Hg. [8. 7] Monitoring Monitor the patient's cardiac activity. Elevate the head of the bed 30° to facilitate intracranial venous drainage. when applicable. Many centers opt for early angiography in all patients. administer oral (PO) acetaminophen (325-650 mg q4-6h). Keep systolic blood pressure 90-140 mm Hg before aneurysm treatment. [8] Fluids and hydration Maintain euvolemia (central venous pressure [CVP]. [8] Use medications that can be titrated rapidly. if cerebral vasospasm is present. automated blood pressure (BP). and end-tidal carbon dioxide. maintain hypervolemia (CVP of 8-12 mm Hg. Emergent ventricular drainage by the neurosurgeon may be necessary. Invasive arterial line monitoring is indicated when dealing with labile BP (common in high- grade subarachnoid hemorrhage). 5-8 mm Hg). Antihypertensive agents were previously advocated for a systolic blood pressure (SBP) greater than 160 mm Hg or a diastolic BP (DBP) greater than 90 mm Hg. as individual practices vary. Target the partial pressure of carbon dioxide (pCO2) at about 30-35 mm Hg to reduce elevated intracranial pressure (ICP). oximetry.

Patients with subarachnoid hemorrhage (SAH) may also have hyponatremia from cerebral salt wasting. Controversial measures A randomized study of patients in an intensive care unit (ICU) demonstrated fewer ischemic events after aneurysmal subarachnoid hemorrhage (SAH) when high-dose magnesium was given for 10 days. but use anticonvulsants in patients who have had a seizure or if local practice dictates routine use. Use of antifibrinolytics. other studies have shown no benefit from magnesium. These agents competitively inhibit plasminogen activation and have been reported to reduce the incidence of rebleeding. to prevent rebleeding is controversial. The presumed mechanism was decreased cerebral vasospasm. prior to transfer. such as mannitol and hyperventilation. use barbiturates or benzodiazepines only to stop active seizures). Seizure prevention Prophylactic use of anticonvulsants does not acutely prevent seizures after subarachnoid hemorrhage (SAH). Consult a neurosurgeon concerning their use. [11] However. Hospitalization and Transfer Admit patients with suspected subarachnoid hemorrhage (SAH) to an intensive care unit (ICU) for serial neurologic examinations and for hemodynamic monitoring. Emergent imaging and intervention may be necessary if mass effect or rebleeding develops. [12] Clearly. Patients with possible ruptured or leaking subarachnoid hemorrhage (SAH) should be transferred emergently to the closest center with computed tomography (CT) scanning and neurosurgical staff. http://emedicine. Other reports warn of their detrimental vasospastic effect and increased occurrence of hydrocephalus. Stabilize patients promptly for transfer in an advanced cardiac life support (ACLS)– monitored unit. Address airway and the possible need for intubation or other emergent interventions.com/article/794076-overview#showall . Begin with anticonvulsants that do not change the level of consciousness (ie. phenytoin first. such as epsilon aminocaproic acid.medscape. further study is indicated. [10] A meta- analysis demonstrated similar findings.Do not overhydrate patients because of the risks of hydrocephalus.