Subarachnoid Haemorrhage: Initial Management
OVERVIEW
Initial management includes
- resuscitation
- specific treatment
- supportive care and monitoring
- disposition
Oli Flower discusses the initial management of aneurysmal SAH in this PK SMACC talk:
RESUSCITATION
- ABCDEFGH approach
- if airway not patent or requires protection -> elective intubation (e.g. RSI with fentanyl, ketamine or thiopentone – avoid hypotension)
- neurogenic cardiomyopathy -> treat dysrhythmias, APO and cardiogenic shock as required
- Treat seizures (occur in 18% of patients) with benzodiazepines and load with phenytoin 18 mg/kg IV
- maintain intravascular volume with isotonic fluids (watch for hyponatraemia) -> target euvolemia, avoid HHH therapy
SPECIFIC THERAPIES
- Treat hypertension
— target BP <140 mmHg; >150 mmHg associated with re-bleeding
— manage with analgesia (e.g. fentanyl) + nimodipine +/- other titratable antihypertensives (e.g. SNP)
— avoid hypotension, leads to cerebral ischemia - correct coagulopathy
— e.g. vitamin K and prothrombinex for warfarin; consider platelets for patients on aspirin and clopidogrel - Treat hydrocephalus
— if obtunded then needs emergency EVD placement
— if no neurosurgeon on site then consider mannitol and urgent retrieval - Dexamethasone used by some to decrease meningeal irritation + oedema -> no evidence
- Seizure prophylaxis
— controversial
— seizures associated with worse prognosis, but phenytoin worsens cognitive outcomes
— phenytoin loading 18mg/kg IV is common in the initial management - Antifibrinolytics, e.g. tranexamic acid
— controversial
— may reduce risk of re-bleed but increase risk of VTE
— some centers give until aneurysm is secured if no VTE risk factors, monitor for DVT - Secure the aneurysm (see CCC entry on clipping versus coiling)
— coil if possible -> better outcomes in terms of disability @ 1 year (controversial ISAT trial)
— clip if uncoilable -> perform within 72 hours
SUPPORTIVE CARE AND MONITORING
- routine monitoring
- arterial line usually required
- CVL if multiple infusions or vasoactive agents required
- avoid Valsalva manouvre
- treat pain and anxiety (e.g. fentanyl +/- benzodiazepines)
- avoid over-sedation which may impair monitoring of neurological status
- head up 30 degrees
DISPOSITION
- best managed at high volume centers with neurosurgical and IR services
- operating theatre if urgent EVD placement required
- ICU if intubated or Neuro HDU prior to securing aneurysm
References and Links
CCC Neurocritical Care Series
Emergencies: Brain Herniation, Eclampsia, Elevated ICP, Status Epilepticus, Status Epilepticus in Paeds
DDx: Acute Non-Traumatic Weakness, Bulbar Dysfunction, Coma, Coma-like Syndromes, Delayed Awakening, Hearing Loss in ICU, ICU acquired Weakness, Post-Op Confusion, Pseudocoma, Pupillary Abnormalities
Neurology: Anti-NMDA Encephalitis, Basilar Artery Occlusion, Central Diabetes Insipidus, Cerebral Oedema, Cerebral Venous Sinus Thrombosis, Cervical (Carotid / Vertebral) Artery Dissections, Delirium, GBS vs CIP, GBS vs MG vs MND, Guillain-Barre Syndrome, Horner’s Syndrome, Hypoxic Brain Injury, Intracerebral Haemorrhage (ICH), Myasthenia Gravis, Non-convulsive Status Epilepticus, Post-Hypoxic Myoclonus, PRES, Stroke Thrombolysis, Transverse Myelitis, Watershed Infarcts, Wernicke’s Encephalopathy
Neurosurgery: Cerebral Salt Wasting, Decompressive Craniectomy, Decompressive Craniectomy for Malignant MCA Syndrome, Intracerebral Haemorrhage (ICH)
— SCI: Anatomy and Syndromes, Acute Traumatic Spinal Cord Injury, C-Spine Assessment, C-Spine Fractures, Spinal Cord Infarction, Syndomes,
— SAH: Acute management, Coiling vs Clipping, Complications, Grading Systems, Literature Summaries, ICU Management, Monitoring, Overview, Prognostication, Vasospasm
— TBI: Assessment, Base of skull fracture, Brain Impact Apnoea, Cerebral Perfusion Pressure (CPP), DI in TBI, Elevated ICP, Limitations of CT, Lund Concept, Management, Moderate Head Injury, Monitoring, Overview, Paediatric TBI, Polyuria incl. CSW, Prognosis, Seizures, Temperature
ID in NeuroCrit. Care: Aseptic Meningitis, Bacterial Meningitis, Botulism, Cryptococcosis, Encephalitis, HSV Encephalitis, Meningococcaemia, Spinal Epidural Abscess
Equipment/Investigations: BIS Monitoring, Codman ICP Monitor, Continuous EEG, CSF Analysis, CT Head, CT Head Interpretation, EEG, Extradural ICP Monitors, External Ventricular Drain (EVD), Evoked Potentials, Jugular Bulb Oxygen Saturation, MRI Head, MRI and the Critically Ill, Train of Four (TOF), Transcranial Doppler
Pharmacology: Desmopressin, Hypertonic Saline, Levetiracetam (Keppra), Mannitol, Midazolam, Sedation in ICU, Thiopentone
MISC: Brainstem Rules of 4, Cognitive Impairment in Critically Ill, Eye Movements in Coma, Examination of the Unconscious Patient, Glasgow Coma Scale (GCS), Hiccoughs, Myopathy vs Neuropathy, Neurology Literature Summaries, NSx Literature Summaries, Occulocephalic and occulovestibular reflexes, Prognosis after Cardiac Arrest, SIADH vs Cerebral Salt Wasting, Sleep in ICU
Journals
- Connolly ES Jr ,et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012 Jun;43(6):1711-37. PMID: 22556195.
- Diringer MN, et al; Neurocritical Care Society. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care. 2011 Sep;15(2):211-40. PMID: 21773873.
- Edlow JA, Samuels O, Smith WS, Weingart SD. Emergency neurological life support: subarachnoid hemorrhage. Neurocrit Care. 2012 Sep;17 Suppl 1:S47-53. PMID: 22932990.
- Hillman J, Fridriksson S, Nilsson O, Yu Z, Saveland H, Jakobsson KE. Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study. J Neurosurg. 2002 Oct;97(4):771-8. PMID: 12405362.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC