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.
Update: Critical Care Management of Patients Following Aneurysmal SAH Guidelines from NCC
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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Professor
Chief, Division of Emergency Critical Care
Director, Resuscitation and Acute Critical Care Unit
Stony Brook Medicine
Stony Brook, NY, USA
No conflicts of interest (coi).
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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.
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
is the article you recommend still the best one? or is there a new update? do you intubate all severe bleeds even if awake and following commands if they are to be transferred?