Dr. Katie Lin and Dr. Jeff Perry discuss essential priorities in managing subarachnoid hemorrhage, including CT plus CTA, nimodipine use, and preventing rebleeding. They highlight prognostic tools for patient counseling. The podcast explores optimizing care, vasospasm, seizure prophylaxis, neuroprognostication, acute management strategies, and emerging trends in emergency medicine.
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Quick takeaways
Prompt diagnosis and management are crucial in subarachnoid hemorrhage to prevent adverse outcomes.
Maintaining euvolemia and proactive monitoring help minimize risks of delayed cerebral ischemia in SAH patients.
Deep dives
Key Initial Priorities in Managing the Undifferentiated Crashing Brain Patient
In managing undifferentiated crashing brain patients, it is crucial to prioritize key initial actions. First, checking glucose levels is vital, especially for those with neurologic complaints or altered level of consciousness. Performing a quick neuroexam, focusing on GCS, eyes, and motor functions, helps identify signs of herniation or deterioration. Avoiding hypotension and hypoxia at all costs is essential, considering early airway management for specific indications. Lastly, swiftly getting the patient to a CT scanner for diagnosis and treatment initiation is crucial to improve outcomes.
Considerations for Imaging in Critical Neurological Deficits
In cases of critical neurological deficits, immediate and efficient imaging is crucial for timely diagnosis and management. Ordering a CT CTA upfront in sick patients allows for prompt identification of hemorrhagic versus ischemic conditions. Early imaging is key to initiating targeted therapies promptly and engaging the appropriate specialists for definitive management. For stable patients with low pretest probability or delayed presentations, a stepwise approach may be appropriate, while critically ill patients require expedited CT CTA for swift diagnosis and intervention.
Managing Raised Intracranial Pressure in Subarachnoid Hemorrhage
Managing raised intracranial pressure (ICP) in subarachnoid hemorrhage patients requires a tiered approach. Start with raising the head of the bed or assuming a reverse trandellenberg position. Consider hyperosmolar therapies and cautious hyperventilation if necessary, avoiding prolonged hyperventilation due to potential ischemic risks. Invasive measures like external ventricular drains or decompressive procedures can be crucial for severe cases, with a focus on temporizing measures to stabilize and prepare patients for definitive interventions.
Preventing Delayed Cerebral Ischemia in Subarachnoid Hemorrhage Patients
Preventing delayed cerebral ischemia after subarachnoid hemorrhage involves understanding the risk factors and proactive measures. Cerebral vasospasm and delayed ischemia are significant concerns post-hemorrhage, with potential devastating outcomes. Initiating nimodipine early and monitoring urine output and sodium levels are critical strategies. Maintaining euvolemia and preventing cerebral salt wasting are key to minimizing ischemic risks, emphasis on prompt diagnosis and targeted therapies to mitigate delayed complications.
Once the diagnosis of nontraumatic subarachnoid hemorrhage (SAH) has been made, our job is not done. Mortality in SAH patients can be up to 30% even without neurological deficit. Paying attention to the time-sensitive details of ED management of SAH patients can have a significant impact on their outcome. In this second part of our 2-part podcast series on subarachnoid hemorrhage with Dr. Katie Lin and Dr. Jeff Perry we answer questions such as: what are the 4 critical priorities in the initial stabilization of the patient with a suspected massive subarachnoid hemorrhage? When is a CT plus CTA of the head indicated up front in the management of patients with suspected subarachnoid hemorrhage? What is the evidence for oral nimodipine in improving outcomes in patients with subarachnoid hemorrhage and how does it work? What can we do in the ED to prevent rebleeding in patients with subarachnoid hemorrhage? What are the simplest and best prognostic tools available for spontaneous subarachnoid hemorrhage to help counsel families and patients? and more...
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