Sub Arachnoid Hemorrhage
Unlock the complexities of Subarachnoid Hemorrhage with this detailed guide. From investigations and medical management for non-operated aneurysms to blood pressure targets and indications for coiling or clipping. Explore medication regimens, pain management strategies, and crucial details on the Hunt-Hess Grading Scale.
2023-12-21 21:23:52 - Editor
NON-OPERATED ANEURYSM
Investigations
- Continuous EKG monitoring for ischemia
- Cardiac enzymes
- MRA brain
Medical Management:
• Dilantin 100 mg po tid
• Nimodipine 60 mg po q4h for prophylaxis against vasospasm for a total of 21 days
a. Hold if SBP < 120
b. If SBP 120-140 range use 30 mg instead
• Pneumoboots / SCDs
• Pain management:
1. Lortab 1-2 tab po q6h prn or
2. Morphine 2mg iv q 2h prn
• Pepcid 20 mg po bid
• Colace 100mg pot id
• Ondansetron 4mg po q6 h prn for nausea
Blood Pressure Management
Non-operated aneurysm
- Target MAP 70-100
- Target SBP 90-140
Clipped aneurysm:
- Target SBP 120-180
If 140/90 - 230/120 on 2 readings 5 minutes apart use Labetelol
- Labetelol 10 mg iv over 2 minutes
- May repeat in 10 minutes at double the dose
- Max cumulative dose in 24 hrs is 300mg
- Hold for HR < 60
If SBP >230 or DBP 121-140 on 2 readings 5 minutes apart
- May still try Labetelol
- If ineffective go to Nicardipine
Nicardipine 5mg /hour infusion.
1. Titrate up by 2.5 mg/h increments at 15 minute intervals.
2. Max rate 15mg/h
3. Once target range reached, reduce to 3mg/h
Indications for Coiling:
• Posterior circulation
• Cavernous segment of ICA
• Neck diameter < 5mm
• Neck to largest diameter ratio < 0.5 (ie if neck diameter is less than half of largest diameter)
Indications for Clipping
• MCA aneurysm
• Giant >25mm
• Very small <3mm
• Associated large hematoma / mass effect
Hunt- Hess Grading Scale
I mild headache
II severe headache
III Severe headache with focal deficit other than cranial nerve palsy
IV stupor
V coma