What are the recommendations for prehospital management of Subarachnoid Hemorrhage (SAH)?

Prehospital Management of Subarachnoid Hemorrhage (SAH)

Prehospital management of SAH should focus on rapid assessment, airway management, and expedient transport to an appropriate facility while avoiding unnecessary on-scene delays. 1

Initial Assessment and Transport

• Emergency medical services (EMS) personnel should maintain a high index of suspicion for SAH in patients presenting with severe headache, altered level of consciousness, or vomiting, even without focal neurological deficits 1
• Rapid assessment and transport model should be employed, similar to that used for acute ischemic stroke 1
• Unnecessary on-scene delays should be avoided to minimize time to definitive care 1
• Pre-notification of the emergency department should be maintained to allow preparation for the patient's arrival 1
• If definitive expertise is not available at the initial receiving hospital, expedient transfer to an appropriate referral center should be considered 1
• Hospitals with low volume of SAH cases (<10 per year) should consider early transfer to high-volume centers (>35 cases per year) with experienced cerebrovascular surgeons and multidisciplinary neurointensive care services 1

Airway Management

• The initial focus should be ensuring and maintaining adequate airway, breathing, and circulation 1
• Although most SAH patients do not present with airway compromise, the potential for neurological deterioration is significant, making airway surveillance paramount 1
• If endotracheal intubation becomes necessary due to decreased level of consciousness, inability to protect airway, or respiratory compromise, it should follow established rapid sequence intubation protocols 1
• During intubation, specific attention should be given to:
  • Preoxygenation 1
  • Pharmacological blunting of reflex dysrhythmia 1
  • Avoidance of unnecessary blood pressure fluctuations 1
• Following intubation, placement of a nasogastric or orogastric tube is recommended to reduce aspiration risk 1
• Appropriate oxygenation without hyperventilation should be maintained and assessed with oximetry 1

Blood Pressure Management

• Blood pressure should be controlled with a titratable agent to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure 1
• Although no well-controlled studies definitively answer whether blood pressure control in acute SAH influences rebleeding, retrospective data suggests rebleeding may be more common with systolic blood pressure >160 mmHg 1
• Avoid unnecessary fluctuations in blood pressure that may increase risk of rebleeding 1

Neurological Assessment

• Emergency care providers should evaluate SAH patients using an accepted grading scale and record it 1
• Commonly used scales include:
  • Hunt and Hess Scale 1
  • Fisher Scale 1
  • Glasgow Coma Scale 1
  • World Federation of Neurological Surgeons Scale 1
• The degree of neurological impairment using these scales is useful for prognosis and triage 1

Common Pitfalls and Caveats

• SAH is frequently misdiagnosed - maintain high suspicion in patients with acute onset of severe headache 1
• Avoid hyperventilation in intubated patients as it may worsen cerebral ischemia 1
• Avoid excessive fluid administration that could worsen cerebral edema, but maintain euvolemia 1
• Do not delay transport for extensive on-scene interventions 1
• Do not administer antiplatelet or anticoagulant medications in the prehospital setting when SAH is suspected 1
• Recognize that SAH patients may rapidly deteriorate, requiring reassessment of airway status 1

Education and Training

• EMS personnel should receive continuing education regarding the importance of rapid neurological assessment when altered level of consciousness is encountered 1
• Training should emphasize recognition of SAH symptoms and the time-sensitive nature of this condition 1