SAH not intubated (ICU)

Template for plan of management (SAH patient, not intubated)

- Neurological checks q1h
- Seizure, fall, aspiration precautions
- Head of bed at 30 degrees at all times
- SBP goal 100-140 (not secured yet)
- 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
- Meds:

  1. Nimodipine 60mg PO q4h
  2. APAP 500 mg PO q6h PRN for pain or headache
  3. Levetiracetam 750mg bid (for seizure prophylaxis)

- Aspiration precautions, head of bed above 30 degrees
- PRN O2
- Baseline CXR
- Meds:

  1. Duonebs q4h

- 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)
- Meds:

  1. Nicardipine drip (target SBP < 140)
  2. Labetalol 10mg IV q4h prn

- Renal function normal
- Monitor daily BMP, Mg, Phos
- Avoid hypotonic fluids as this can worsen cerebral edema
- Meds:

  1. NS @ 75ml/h

- NPO for now till speech evaluation
- Last BM: unknown
- Meds:
1. Docusate 100 mg PO TID
2. Pantoprazole 40mg tab daily
- FSBS q6hr while NPO/TF
- Check HgbA1c, TSH
- Meds:

  1. Insulin SS q6h while NPO then ACHS
  2. Hypoglycemia protocol

- Monitor CBC daily
- SCDs for prophylaxis; no heparins given acute subarachnoid bleed
- Meds:

  1. None

Infectious Disease:
- Current access: PIVs (placed), will place PICC line
- Keep normothermic, aggressive fever control as it worsens neurological outcomes
- Meds:
​      1. APAP 500mg q6hr PRN for fever >38.3

DVT: SCDs, no anticoagulation in the setting of recent subarachnoid bleed
GI: famotidine, docusate
Physical therapy
Occupational therapy
Speech therapy
Case Management
Social Work
Discharge Planning:
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. 
- Meds:
-> 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. 
- Meds:
 -> 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