Subarachnoid Hemorrhage EMCRIT # 8

Summary by Elizabeth Dei-Rossi, MD


Tip 1 – get the neuro exam prior to intubation

Tip 2 – neuroprotective intubation

  • If GCS < 8, then intubate
  • Premedication
    • Lidocaine 1 to 1.5 mg/kg – blunts reflex increase in BP from intubation
    •  Fentanyl 200 micrograms – works as a SYMPATHOLYTIC (for a neuroprotective intubation)
    • Give 3 minutes prior to intubation
  • Paralytic – succinylcholine
  • Induction agent
    • If BP is low or normal use Etomidate
    • If BP is elevated use Propofol

Tip 3 – treat pain, if intubated then sedate

Tip 4 – treat vasospasm with an anti-vasospastic agent

  • Nimodipine 60mg PO or NGT

Tip 5 – BP control – want MAP of around 80 because that gives CPP of about 60

  • Agents of choice – cardene (nicardipine) or labetalol
  • If good mental status
    • History of HTN then MAP < 100 and systolic < 160
    • No history of HTN then MAP = 80 and systolic < 140
  • If obtunded MAP around 80, until ICP monitoring is in place
  • If low BP then give fluids, pressors, and inotropes

Tip 6 – give anti-seizure prophylaxis – phenytoin or fosphenytoin

Tip 7 – give anti-fibrinolytics – amicar (ask neurosurgeon first)

Tip 8 – Reverse coagulopathy

  • If on Coumadin, then give PCC and vit K IV
  • If on aspirin, then give DDAVD
  • If on Plavix, then give platelets

Tip 9 – Consider the heart – can get EKG changes, dysrhythnias, LV stunning, and infarcts
get an EKG, consider echo/troponins

  • Brain stem irritation by blood can cause sympathetic surge

Tip 10 – ICP monitoring and CPP, place IVC

• EVD (external ventricular drain) – will drain hydrocephalus and monitor ICP
• Cerebral perfusion pressure goal 55-60
• If ICP > 20 then give mannitol or 3% saline 250cc bolus over 10 min


Post-test Here.

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One Response to Subarachnoid Hemorrhage EMCRIT # 8

  1. Daniel Lakoff says:

    With regards to Tip#2, the medication choice is not that straightforward, and has to be considered and decided upon largely in part with consideration of the patient’s MAP. If the patient is hypotensive, we may not want to further decrease the patient cerebral perfusion pressure by premedicating the patient. As well, we by choosing ketamine as an induction agent in a hypotensive patient, we would actually benefit the patient by increasing the CPP. See the reference for the quick read reference by SW.

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