Subarachnoid Haemorrhage: Initial Management


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:


  • 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


  • 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


  • 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


  • 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



  • 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.

CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.