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
- Subarachnoid Haemorrhage (SAH)
- Coiling versus Clipping in aneurysmal Subarachnoid Haemorrhage
- Vasospasm in Subarachnoid Haemorrhage
- Subarachnoid Haemorrhage: Initial Management
- Subarachnoid Haemorrhage: ICU Management
- Monitoring in Subarachnoid Haemorrhage
- Subarachnoid Haemorrhage Grading Systems
- Subarachnoid Haemorrhage: Prognostication
- Transcranial Doppler
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