Back to Basics: Subarachnoid Hemorrhage Management

Subarachnoid Hemorrhage Management Pearls

1.  SAH requiring intubation:

  • Consider fentanyl and lidocaine 3-4 min pre-intubation (if time permits) for neuroprotection, though data regarding effectiveness for both agents is inconsistent
  • Important to avoid hypotension during intubation - keep this in mind when choosing RSI medicaitons
  • Pain management & sedation post intubation are critical - have propofol and fentanyl at the bedside during intubation

2.  Hypertensive SAH:

  • No clear BP target - some studies initially suggested lowering SBP<140, others show no difference between SBP<180 & <140
  • Commonly used agents:  labetalol, nicardipine, enalapril
  • Avoid nitroprusside & nitroglycerin because these can increase ICP

3.  SAH in patient taking anticoagulations/antiplatelets:

  • Hold all anticoagulants & antiplatelets after diagnosis of SAH
  • Agents should be reversed immediately
    • *Controversial:  PATCH Trial - platelet transfusion increased mortality in patients taking antiplatelet agents with acute nontraumatic SAH

4.  Seizure Prophylaxis

  • Consider it
  • Remains controversial, best to consult with neurosurgeon

5.  Prevention of Vasospasm

  • Nimodipine within 96 hrs of symptoms
    • Must be given PO or via NGT, not IV



Baharoglu et al. “Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial.” The Lancet. 2016, Volume 387, Issue 10038: 2605 - 2613.

Bederson et al. “Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Statement for Healthcare Professionals From a Special Writing Group of the Stroke Council, American Heart Association.” Stroke. 2009, 40: 994-1025.


Caro, D.  "Pretreatment medications for rapid sequence intubation in adults outside the operating room."  UpToDate.  July 2017.


Singer R, Ogilvy C, Rodorf G.  “Treatment of Aneurysmal Subarachnoid Hemorrhage.” UpToDate.  June 2017 <>


Tintinalli, JE. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education LLC, 2016.