Non-traumatic subarachnoid hemorrhage
-- Sx: Sudden-onset severe headache, N/V, meningismus (neck stiffness, pain with flexion), AMS, ± Seizures, ± syncope
-- Hx: HTN, smoking, aneurysm or prior SAH, Anticoagulant/antiplatelet use, Cocaine/stimulant use, PCKD
-- PE: Brudzinski Sign (pt flex knee with passive neck flex), No Focal neurologic deficits, CNII-VII intact
-- W/U: CTH noncon, if Neg w/high suspicion → LP (xanthochromia, ↑ RBCs), CBC,BMP,Coags,type&screen, CTA or MRA to Finds the aneurysm (source of bleed),
-- MEDS:
-- DDX/Cause: ruptured aneurysm (MC), Non-aneurysmal SAH, Infection-related if signs of infection
-- Hunt-Hess (clinical severity NOW) Grade1-5 (3-worse,4-critical,5-very poor prognosis)
-- Modified Fisher (future risk (vasospasm). CT based) grade 1-4 (VL/L/H/Mod)

Hunt & Hess Classification of SAH Severity:

Asymptomatic or mild headache or nuchal regidity
Severe headache, stiff neck, no focal neuro deficits except CN palsy
Drowsy or confused, mild focal neuro deficits
Stuprous, moderate or severe hemiparesis
Coma, decerebrate posturing

Fisher Grading Scale for SAH (appearance of blood on CT)

No blood detected
Diffuse deposition or thin layer with all vertical layers less than 1 mm thick
Localized clot or vertical layers > 1 mm thick
Intracerebral or intraventricular clot with diffuse or no subarachnoid blood

DATA: temp,BP, Na, glucose
ONE:
PE: volume

Plan

initial / Definitive Management

SAH order set applied; NIR/NSG on board; CT-angio ordered
Urgent aneurysm securement (coiling vs clipping) to prevent rebleeding

Blood Pressure

Goal:
- Pre-secure: SBP 120–160 (<160)
- Post-secure: SBP <180–200
Nicardipine drip ± Labetalol 10 mg IV PRN / esmolol

Neuro ICU Care

Head of bed >30° (improves venous drainage)
Neuro checks: q15min x2h → q30min x6h → q1h x16h (per protocol)
ICU monitoring for 7–10 days post bleed

Volume / Electrolyte / Metabolic

Maintain normonatremia, euvolemia, euglycemia, euthermia
Strict I/Os
SSI + CBG checks
If salt wasting (CSW):
(Na↓, UNa>40, Uosm>100, BUN/Cr >20, ↑UOP >1–2 mL/kg/hr)
→ 3% NS 250–500 mL bolus → 75–100 mL/hr gtt
→ Na q4h
If hypovolemia: NS
If hypernatremia: fluids ± desmopressin
PRN APAP

Vasospasm Prevention / Monitoring

Nimodipine 60 mg q4h x21 days from SAH onset
Daily TCD starting post-SAH day 3 (or post-procedure day 1)

Anticoagulation / DVT Prophylaxis

Reverse anticoagulation if needed; hold all AC/AP
DVT ppx: SCDs → SQ heparin 5000u BID (start 24h post-procedure)

Seizure Management

Consider cEEG + Neuro consult if concern for subclinical status epilepticus
If seizure:
→ Ativan 2–4 mg IV, repeat q5 min (max ~8 mg)
→ Load Keppra 60 mg/kg (max ~4500 mg IV once)
→ Then 1000 mg BID

Neuro Decline / Vasospasm Concern

If new focal deficits:
→ Induce HTN (SBP 160–220) with pressors (e.g., levo)
→ STAT CT head + CTA head/neck ± CT perfusion (CTP)

Hydrocephalus / IVH / ↑ICP

Contact NSG if:
- Acute hydrocephalus on CT
- Declining mental status, HA + vomiting, lethargy/coma
- Intraventricular hemorrhage

→ Think CSF obstruction + ↑ICP → may need EVD (rare: decompressive surgery)

If ICP monitoring:
- Goal CPP (MAP − ICP) = 60–70
- Use pressors (phenylephrine/norepinephrine) to augment MAP
- EVD to gravity, leveled at cmH₂O above tragus

Herniation (EMERGENCY)

Signs: ↓ GCS, blown pupil, posturing, Cushing triad
Immediate ICP reduction (minutes matter):
- 3% saline (preferred)
- Mannitol 0.5–1 g/kg IV bolus (repeat 0.25–0.5 g/kg PRN; goal osm <300–310)
Emergent NSG

Supportive

PT / OT / SLP ordered
Continue statin if patient already on it

Other

Consider therapeutic LP if HA persists (not at this time)

Disposition

If stable neuro exam → transfer to floor ~day 10

Watch for complications including rebleeding, vasospasm with delayed cerebral ischemia, seizures, hyponatremia (CSW/SIADH), cardiac dysfunction, neurogenic pulmonary edema, and obstructive hydrocephalus s/p EVD (monitor ICP/CPP and drain function).

DOT