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History
- Sudden and maximal in onset
- Compared to previous headaches
- Family history of aneurysm
- Associated Symptoms
- Photophobia
- Visual Changes
- Neck Stiffness
Exam
- Full neuro examination
- Cranial nerves
- Visual fields
- Speech
- Cerebellar (finger-nose)
- Motor
- Sensation
- Gait
Testing Plan
- Non-contrast head CT
- Excellent sensitivity <6 hours from onset
- Lumbar puncture
- >100 RBCs in tube 4
- Can be difficult to interpret after a traumatic lumbar puncture
- Xanthochromia
- >100 RBCs in tube 4
Treatment Plan
- Prevent rebleeding
- Keep SBP <140
- Nicardipine
- Reverse any anticoagulants
- Vitamin K
- Prothrombin complex concentrate
- Fresh frozen plasma
- Keep SBP <140
- Prevent vasospasm
- Nimodipine PO
- Prevent delayed ischemia
- Avoid hyperthermia
- Avoid hyper/hypoglycemia
- Prevent seizures
- Levetiracetam (aka Keppra)
Additional Reading
- Ottawa Subarachnoid Hemorrhage (MDCalc)
am I right in thinking we should grab an attending prior to the detailed neuro exam if the history is concerning for SAH?
If the patient is ill appearing, severe distress, grossly unstable vitals, etc, it is important to immediately get your attending. If the patient is stable, do a thorough neuro exam before you present (should only take 1-2minutes).