What is the paramedic's role in managing a suspected subarachnoid hemorrhage?

Paramedic's Role in Subarachnoid Hemorrhage Management

Paramedics play a critical role in the early identification, stabilization, and rapid transport of patients with suspected subarachnoid hemorrhage (SAH), as immediate intervention can significantly reduce mortality rates which can reach 70-90% in cases of rebleeding.1

Initial Assessment and Stabilization

Rapid Neurological Evaluation

• Assess level of consciousness using the Glasgow Coma Scale (GCS) 1
• Document key symptoms:
  • Sudden onset severe headache ("worst headache of life")
  • Nausea and vomiting
  • Neck pain or stiffness
  • Photophobia
  • Altered mental status

Airway Management

• Secure airway if GCS ≤8 or deteriorating neurological status
• Endotracheal intubation should be followed by placement of nasogastric/orogastric tube to prevent aspiration 1
• Maintain appropriate oxygenation without hyperventilation 1
• Monitor oxygen saturation continuously

Hemodynamic Management

• Establish IV access immediately
• Control blood pressure to prevent rebleeding
  • Target systolic BP <160 mmHg using titratable agents 2
  • Avoid excessive BP reduction which may compromise cerebral perfusion
• Monitor for signs of neurogenic pulmonary edema, which occurs in up to 20% of SAH patients 1

Transport Considerations

Decision Making

• Transport to a facility with neurosurgical capabilities whenever possible
• If definitive care is not available at the initial receiving hospital, prepare for expedient transfer to an appropriate referral center 1

During Transport

• Position patient with head elevated 30° to reduce intracranial pressure 2
• Minimize stimulation and maintain a calm environment
• Consider administering tranexamic acid to reduce risk of early rebleeding during transfer 2
• Avoid hypotonic fluids to prevent cerebral edema 2
• Maintain euvolemia 2

Documentation and Communication

• Document using an accepted SAH grading system (Hunt and Hess Scale or World Federation of Neurological Surgeons Scale) 1
• Clearly communicate time of symptom onset to receiving facility
• Report any changes in neurological status during transport

Medication Management

• Administer nimodipine if available and directed by medical control - indicated for improving neurological outcomes in SAH patients 3
• Pain management with cautious use of analgesics that won't mask neurological deterioration
• Antiemetics for nausea and vomiting
• Seizure prophylaxis if directed by medical control

Common Pitfalls to Avoid

• Misdiagnosis: Up to 5% of SAH patients are initially misdiagnosed 4
• Delayed transport: The risk of rebleeding is highest in the first hours after initial hemorrhage 1
• Inappropriate blood pressure management: Both hypertension and hypotension can worsen outcomes
• Hyperventilation: Can cause cerebral vasoconstriction and worsen cerebral ischemia
• Failure to recognize deterioration: Continuous neurological reassessment is essential

Special Considerations

• Be vigilant for signs of increasing intracranial pressure (declining GCS, pupillary changes, Cushing's triad)
• Recognize that SAH can trigger cardiac abnormalities including arrhythmias and ECG changes
• Maintain normothermia as fever can worsen neurological outcomes
• Monitor for and treat seizures if they occur

Remember that early intervention and rapid transport to definitive care significantly improve outcomes in SAH patients, with treatment delays potentially having adverse effects on patient survival and functional recovery 1.