EMCrit Podcast 8 – Subarachnoid Hemorrhage

This week’s podcast is on the management of a the patient with SAH. It’s not a complete review, just some tips and reminders.

Best article for EM that I’ve found, comes out of Columbia

For more reviews on mostly ICU issues see here and here.

1. Get a neuro exam before you intubate

2. Intubation

Give pretreatment, now just lidocaine and fentanyl

Etomidate or propofol; plus sux.

Most experienced intubater should perform laryngoscopy

3. Treat Pain

and if intubated, give sedation

4. Treat Vasospasm

give nimodipine 60 mg PO or NGT

5. BP Control

place a-line

treat pain first

Give Labetalol or Nicardipine to achieve the patient’s baseline BP if the patient has good mental status

if they are obtunded, be a bit more conservative until ICP monitoring is in place

If MAP is below 80, give fluids, pressors, and inotropes

6. Anti-seizure prophylaxis

Load with phenytoin or fosphenytoin

7. Anti-fibrinolytics

Amicar is the main one these days; ask your neurosurgeon/neurointensivist on a case-by-case basis

see ehced.org for drip sheets

8. Reverse Coagulopathy

9. Think Heart

these patients can get EKG changes, dysrhythmias, LV stunning, and frank infarcts from their SAH

10. ICP ASAP

get the neurosurgeons to get the EVD (external ventricular drain) aka IVC (intraventricular catheter) in place as soon as possible

keep ICP < 20 and CPP > 55-60

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Comments

  1. Dr.Falah Hafuth says:

    very good refreshing talk , well done
    Would you intubat the patien if the GCS more than 10 , but the transfer time (by EMS) take 2 hours?
    Thank you

    • great question. I would intubate this patient but the key is to sedate them with propofol for the transport so that the receiving hospital can extubate on arrival if the mental status is still good.

  2. John Paige III says:

    Would you intubate a patient with a GCS of 15 with a normal neurological status and transfer 15 minutes away?

    I ran into this problem on shift the other night and did not to preserve the neurological exam for the neurosurgeons, I don’t know if it is the right or wrong move.

    Thanks,

    JP3

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