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 < https://www.uptodate.com/contents/treatment-of-aneurysmal-subarachnoid-hemorrhage>
Tintinalli, JE. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education LLC, 2016.