Once the diagnosis of nontraumatic subarachnoid hemorrhage (SAH) has been made, our job is not done. Mortality in SAH patients can be up to 30% even without neurological deficit. Paying attention to the time-sensitive details of ED management of SAH patients can have a significant impact on their outcome. In this second part of our 2-part podcast series on subarachnoid hemorrhage with Dr. Katie Lin and Dr. Jeff Perry we answer questions such as: what are the 4 critical priorities in the initial stabilization of the patient with a suspected massive subarachnoid hemorrhage? When is a CT plus CTA of the head indicated up front in the management of patients with suspected subarachnoid hemorrhage? What is the evidence for oral nimodipine in improving outcomes in patients with subarachnoid hemorrhage and how does it work? What can we do in the ED to prevent rebleeding in patients with subarachnoid hemorrhage? What are the simplest and best prognostic tools available for spontaneous subarachnoid hemorrhage to help counsel families and patients? and more...



Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul

Written Summary, algorithm and blog post by Hanna Jalali, edited by Anton Helman May, 2024

Cite this podcast as: Helman, A. Perry, J. Lin, K. Management of Spontaneous Subarachnoid Hemorrhage. Emergency Medicine Cases. May, 2024. https://emergencymedicinecases.com/ed-management-subarachnoid-hemorrhage. Accessed November 19, 2024

Résumés EM Cases 

Go to part 1 of this 2-part podcast on subarachnoid hemorrhage

Management of the undifferentiated crashing brain: Management of the patient with a suspected subarachnoid hemorrhage prior to CT imaging

Clinical features on their own have shown to not be reliable in distinguishing ischemic versus hemorrhagic CNS insult. While patients with head bleeds are more likely to complain of headache, nausea and vomiting compared to patients with ischemic strokes, a significant minority of patients with ischemic strokes do have these symptoms. Definitive management requires neuroimaging however we need to be able to empirically resuscitate the sick neurological patient keeping in mind important factors for the crashing brain.

4 critical priorities in the first 10 minutes:



* Check and correct the glucose or empirically give an amp of D50W

* Perform a rapid neurological exam prioritizing GCS, eyes (reaction to light, discongugate gaze, deviation), and motor response

* Avoid hypotension and hypoxia at all costs considering early airway management/capture if needed

* Resuscitate to get to the scanner so targeted treatment can be initiated after diagnosis is made



Initial imaging for suspected subarachnoid hemorrhage: Non-contrast CT vs CT plus CTA upfront?

In the crashing neurological patient we need more information than a plain CT head can offer to drive definitive management. The delay to definitive management can mean loss of brain viability. If available at your center, consider CT + CTA as the initial imaging modality of choice patients who:



* Have neurological deficits: speech or motor deficit, vision loss, decreasing or low GCS.

* Pre-existing intracranial vascular abnormality

* Have a contraindication to LP

* With shared decision-making >6 hours post headache onset (see SAH Part 1 <a href="https://emergencymedicinecases.