Template for plan of management (SAH patient, intubated)
- Neurological checks q1h
- Seizure, fall, aspiration precautions
- Head of bed at 30 degrees at all times
- SBP goal 100-140 (aneurysm is not secured yet)
- Soft restraints while life saving devices in place (reviewed and necessary)
- Neurosurgery managing EVD
- No free water, mix everything in NS as this can worsen cerebral edema
- PT/OT/ST consults initiated
- TCD will be done daily
Nimodipine 60mg PO q4h
APAP 500 mg PO q6h PRN for pain or headache
Levetiracetam 750mg bid (for seizure prophylaxis)
- Aspiration precautions, head of bed above 30 degrees
- PRN O2
- Chest PT with vest q4hr
- Baseline CXR
- Suctioning q1-2 hours
- Continuous cardiac telemetry
- SBP goal 100-140 (source of bleeding is unsecured yet)
- TTE for baseline EF (to guide IVF, cardene and pressor therapy if required)
Nicardipine drip (target SBP < 140)
Labetalol 10mg IV q4h prn
- Renal function normal
- Monitor daily BMP, Mg, Phos
- Foley with temperature probe for strict I&O monitoring in critical care setting
- Avoid hypotonic fluids as this can worsen cerebral edema
NS @ 75ml/h
- NPO for now till speech evaluation
- Place Dobhoff tube for medication/nutrition; Abdominal X-ray to confirm placement ordered
- Start tube feeding with Peptamen 1.5 @ 10cc/hr and titrate to goal 50cc/hr as tolerated
- Hold TF for residuals > 300
- Last BM: unknown
1. Docusate 100 mg PO TID
2. Pantoprazole 40mg tab daily
- FSBS q6hr while NPO/TF
- Check HgbA1c, TSH
Insulin SS q6h while NPO then ACHS
- Monitor CBC daily
- SCDs for prophylaxis; no heparins given acute subarachnoid bleed
- Current access: PIVs (placed), will place PICC line
- Keep normothermic, aggressive fever control as it worsens neurological outcomes
1. APAP 500mg q6hr PRN for fever >38.3
DVT: SCDs, no anticoagulation in the setting of recent subarachnoid bleed
GI: famotidine, docusate
Patient requires ICU level of care for monitoring of potential complications of SAH (rebleeding, vasospasm, hydrocephalus)
Patient was discussed with the neurocritical care attending who agrees with current plan of management.
-> Nurses usually do MEND exam .
-> Seizure precautions means bed at low level, rails are up & alarm is on.
-> Head position has been debated, flat to increase blood flow versus up to avoid aspiration. NEJM study in 2017 showed no difference in outcomes.
-> SBP goal:
- Before securing aneurysm with no concern for elevated ICP (no ICH, IVH, or EVD was placed): < 140
- Before securing aneurysm with concerns for elevated ICP: < 160
- After securing aneurysm: < 180
-> TCD should be done at least daily [Class IIa]
-> Nimodipine doesn't prevent vasospasm, rather it improves neurological outcome in case of delayed cerebral ischemia (DCI). Dose is 60mg q4h can be changed to 30mg q2h if patient is hypotensive. [Class IA]
-> Short course of seizure prophylaxis (7 days) can be used [Class IIb]
-> SBP goal as mentioned above (SBP either less than 140, 160 or 180)
-> TTE is needed to guide fluid balance management as these induced hypertension may be needed in case of vasospasm.
-> CCB drip (Nicardipine drip) is preferred for BP control, although it decreases SBP, not associated with decrease in cerebral oxygen tension.
-> Watch for cerebral salt wasting or SIADH. Both can cause hyponatremia, CSW is associated with hypovolemia (low CVP, dry skin, tachycardia, orthostasis, hematocrit, serum & urine osmolarity) while SIADH is associated with either euvolemia or hypervolemia.
->Foley only placed for confused patients, otherwise urinal should be used.
-> Maintenance isotonic IVF should run at 1-1.5 ml/kg/h
-> Patients with elevated INR, it should be corrected to target INR < 1.3
-> Heparin for DVT prophylaxis should be started within 48h
-> PICC or central line can be used
-> for central fever, you can use acetaminophen -> ibuprofen -> bromocriptine -> gabapentin -> propranolol
Complications of aSAH:
- Rebleeding: Rebreeding occur in 4:14% of patients with aSAH. Maximum risk is mainly in first 12 hours (third of rebreeds occur in first 2 hours, hand of rebreeds occur in first 6 hours).
- Vasospasm: Occurs in 70% of patients. It can occur any time within first 21 days after onset however peak window is between 7-21 day. Incidence of ischemia after angiographically-seen vasospasm is 50%.
- DCI (delayed cerebral ischemia): occurs in 30% of patients. Although most DCI is caused by vasospasm, a large set of patients develop DCI in absence of vasospasm. Postulated etiologies for non-vasospasm DCI include early brain injury (EBI), microcirculatory dysfunction with loss of autoregulation, cortical spreading depolarization (CSD), and microthrombosis. Only nimodipine shown to prevent against DCI.
- Hydrocephalus: 20-30% of aSAH patients develop hydrocephalus which can be acute (within 3 days) or chronic (after weeks or months).
Hunt and Hiss:
Mild Headache, Alert and Oriented, Minimal (if any) Nuchal Rigidity
Full Nuchal Rigidity, Moderate-Severe Headache, Alert and Oriented, No Neuro Deficit (Besides 6th CN Palsy)
Lethargy or Confusion, Mild Focal Neurological Deficits
Stuporous, More Severe Focal Deficit
Comatose, showing signs of severe neurological impairment (ex: posturing)