Subarachnoid  Haemorrhage

You are the neurosurgery CT1 called to A&E to see a 42-year-old woman who had a sudden onset severe “thunderclap” headache 2 hours ago followed by a brief loss of consciousness. The ED team have arranged a CT scan which they have asked you to look at. How would you proceed?

Example answer introduction

I would perform an initial assessment and stabilisation, take a history and perform a focused examination, then put in place an initial management plan and inform my registrar. 

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the CCRISP / Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, blood glucose, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

If she is drowsy I would read the medical notes, speak to nursing staff and any relatives present for further information. 

 

  • Allergies

  • Medications – anti-epileptics, anticoagulants, 

  • Past medical history – hx of epilepsy, diabetes

  • Last meal

  • Events leading up to this point – Neck stiffness, pyrexia, blurred vision, seizures, head trauma

Initial examination and investigations

Full neurological examination

 

  • Signs of raised ICP

  • Cranial nerve examination

  • Peripheral nerve examination

  • Cerebellar examination

 

I would then arrange further investigations following discussion with the neurosurgical registrar;

 

  • CT brain

  • Lumbar puncture

 

This depending on the severity of the bleed she will need admission to the neurosurgical ward or ICU. 

Example questions to progress the station

Q1 Which further investigations may be performed?

 

  • Digital subtraction angiography is the gold standard for determining aetiology of the bleed and the anatomy of the intracerebral vasculature. 

  • CT angiography and MR angiography are useful for screening and to aid pre-operative planning

 

Q2 What are the complications of sub-arachnoid haemorrhage?

  • Re-bleeding

  • Delayed cerebral ischaemia

  • Mass effect - Raised ICP

  • Hydrocephalus

  • Seizures 

  • Hyponatraemia

  • Cardiac abnormalities 

Q3 What would immediate management of this patient entail?

Initial management

  • Strict bedrest at 30 degrees

  • Oral nimodipine 60mg 4 hourly for 21 days after initial bleed (contra-indicated within 4 weeks of myocardial infarction or in unstable angina, must start within 4 days of rupture)

  • Maintenance IV fluids

  • Analgesia

  • Anti-emetics

  • Laxative

  • Analgesia

  • Keep nil by mouth

  • Hourly neuro-observations

  • Prep for theatre – may go for aneurysm clipping, in which case crossmatch 4 units of blood

  • Senior review by neurosurgical registrar

  • Keep patient and any relatives informed 

  • Document, document, document!!!

 Escalation
This is a condition you will not be asked to manage on your own. A basic knowledge of how it presents and immediate management will be required. 
Escalation must include:
- Neurosurgical Registrar
- ICU/Neuro-critical care
Useful Resources

European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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