EMCrit Podcast 8 – Subarachnoid Hemorrhage - a podcast by Scott D. Weingart, MD FCCM

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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