Subarachnoid Haemorrhage Patient Hot Case

GENERAL APPROACH

  • Hemisphere
  • Site
  • Territory
  • Complications
  • Neurological – bleeding, seizure, hydrocephalus, vasospasm, increased ICP
  • Respiratory – aspiration, neurogenic pulmonary oedema
  • Cardiovascular – AMI
  • Electrolytes – SIADH, CSW, DI
  • Treatment done
  • Management

INTRODUCTION

CUBICLE

  • long/short stay
  • organ failures

INFUSIONS

  • nimodipine
  • anti-hypertensives (unclipped aneurysms)
  • vasopressors (haemodynamic augmentation)
  • sedatives

VENTILATOR

  • mode
  • level of support
  • level of oxygenation: FiO2, PEEP
  • high PEEP: aspiration, neurogenic pulmonary oedema, basal atelectasis

MONITOR

  • arterial trace: MAP, swing, pulsus paradoxus, pulse pressure
  • ECG: arrhythmia
  • CVP: number, waveform
  • ICP monitoring: high grade, to detect rebleeding or hydrocephalus
  • temperature: SIRS

EQUIPMENT

  • EVD: hydrocephalus management
  • IDC: polyuria
  • femoral artery sheath if recent cerebral angiogram or endovascular coiling

QUESTION SPECIFIC EXAMINATION

  • neurological

-> head: EVD, craniotomy
-> unconscious: GCS, meningism, subhyaloid haemorrhages
-> conscious

  • Localizing lesion(1) 3rd nerve: PCOM
    (2) hemiplegia (leg>arms): ACOM
    (3) brainstem signs: PCOM
  • hands/arms -> head -> chest -> abdo -> legs/feet -> back

-> general:
-> cardiovascular:
-> respiratory: aspiration pneumonia, neurogenic pulmonary oedema
-> abdominal: polycystic kidney disease,
-> lower limbs:

  • urine output over last 12 hours: polyuria (DI or CSW)
  • when sedation/paralysis ceased
  • asked to see CT and angiography results

RELEVANT INVESTIGATIONS

  • CT head
  • CXR
  • electrolytes: Na+
  • FBC: WCC, Hb, platelets
  • other organ failures
  • ABG: gas exchange, metabolic state

OPENING STATEMENT

=

  • Hemisphere
  • Site
  • Territory
  • Complications
  • Neurological – bleeding, seizure, hydrocephalus, vasospasm, increased ICP
  • Respiratory – aspiration, neurogenic pulmonary oedema
  • Cardiovascular – AMI
  • Electrolytes – SIADH, CSW, DI
  • Treatment done
  • Management

DISCUSSION


CCC 700 6

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

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