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

References

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.