What are the initial management orders for a patient with a subarachnoid hemorrhage?

Initial Management Orders for Subarachnoid Hemorrhage

Immediately transfer the patient to a high-volume center (>35 SAH cases/year) with neurosurgical, neuroendovascular, and neurointensive care capabilities, admit to a neurocritical care unit, start oral nimodipine 60 mg every 4 hours, control blood pressure with titratable agents targeting systolic <160 mmHg, and arrange urgent aneurysm evaluation for early repair. 1, 2

Immediate Resuscitation and Stabilization

Airway and Breathing

• Intubate if Glasgow Coma Scale ≤8, inability to protect airway, or severe respiratory compromise to optimize cerebral oxygenation and prevent aspiration 3
• Maintain normoxia and normocapnia; avoid hypoxia which worsens secondary brain injury 3

Blood Pressure Management

• Control blood pressure with titratable intravenous agents (nicardipine, labetalol, clevidipine) to balance rebleeding risk against maintaining cerebral perfusion 1
• Target systolic blood pressure <160 mmHg prior to aneurysm securing 1
• Avoid severe hypotension, hypertension, and blood pressure variability 2
• If patient is on anticoagulation, emergently reverse it 2

Neurological Assessment

• Rapidly grade clinical severity using Hunt-Hess or World Federation of Neurological Surgeons (WFNS) scale as this is the strongest predictor of outcome 1
• Perform frequent neurological assessments to detect deterioration 2

Diagnostic Workup

Imaging

• Non-contrast head CT is the initial diagnostic test 1
• If CT is non-diagnostic but clinical suspicion remains high, perform lumbar puncture looking for xanthochromia and elevated red blood cell count 1
• Digital subtraction angiography (DSA) with 3D rotational angiography is indicated to identify the aneurysm and plan treatment (coiling vs clipping) 1

Neuroprotection

Nimodipine Administration

• Start oral nimodipine 60 mg every 4 hours within 96 hours of hemorrhage onset and continue for 21 consecutive days 1, 2, 4
• This is a Class I, Level A recommendation that improves neurological outcomes (though not by preventing vasospasm) 1
• If patient cannot swallow: puncture both ends of capsule with 18-gauge needle, extract contents into oral/NG syringe labeled "Not for IV Use," and administer via NG tube followed by 30 mL normal saline flush 4
• Never administer nimodipine intravenously—this can cause fatal hypotension 4
• Reduce dose to 30 mg every 4 hours in patients with hepatic cirrhosis 4

Aneurysm Management

Timing and Approach

• Secure the aneurysm as early as feasible (ideally <24 hours from ictus) to prevent rebleeding, which is frequently fatal 1
• Early treatment (<24 hours) reduces rebleeding risk and facilitates management of delayed cerebral ischemia 1

Treatment Modality Selection

• Evaluation by both neurosurgical and endovascular specialists is mandatory to determine optimal approach 1, 2
• For aneurysms amenable to both techniques: endovascular coiling is preferred over surgical clipping for anterior circulation aneurysms to improve 1-year functional outcomes 1, 2
• For posterior circulation aneurysms: coiling is strongly preferred over clipping (RR 0.41 for death/dependency) 1
• Consider surgical clipping for: large intraparenchymal hematomas (>50 mL) with middle cerebral artery aneurysms 1
• Consider endovascular coiling for: elderly patients (>70 years), poor-grade SAH (WFNS IV/V), and basilar apex aneurysms 1
• Goal is complete aneurysm obliteration whenever feasible as incomplete obliteration substantially increases rebleeding and retreatment risk 1

Prevention of Complications

Hydrocephalus Management

• If acute symptomatic hydrocephalus develops, perform urgent CSF diversion via external ventricular drain (EVD) or lumbar drain depending on clinical scenario 1, 2

Delayed Cerebral Ischemia Prevention

• Maintain euvolemia and normal circulating blood volume—do NOT induce prophylactic hypervolemia as this does not improve outcomes and may be harmful 1, 2
• Avoid prophylactic hemodynamic augmentation or balloon angioplasty before vasospasm develops 1
• Use transcranial Doppler to monitor for vasospasm development (Lindegaard ratios 5-6 indicate severe spasm) 1, 2
• If symptomatic delayed cerebral ischemia develops: induce hypertension while maintaining euvolemia unless baseline BP is already elevated or cardiac status precludes it 1, 2

Seizure Prophylaxis

• Avoid phenytoin for seizure prophylaxis as it is associated with excess morbidity and mortality 2
• Consider alternative antiepileptic agents if seizure prophylaxis is deemed necessary 5

Venous Thromboembolism Prophylaxis

• Initiate VTE prophylaxis once the aneurysm is secured 2
• Screen for heparin-induced thrombocytopenia and deep venous thrombosis with early identification and targeted treatment 1

Monitoring and Supportive Care

ICU Management

• Admit to neurocritical care unit with specialized multidisciplinary team using evidence-based protocols 2, 6
• Implement validated dysphagia screening protocols 2
• Use standardized ICU care bundles if mechanical ventilation required 2
• Avoid routine use of statins, IV magnesium, and endothelin antagonists as they have not been shown to improve outcomes 2

Transfer Considerations

• Low-volume hospitals (<10 SAH cases/year) should transfer patients early to high-volume centers with experienced cerebrovascular surgeons, endovascular specialists, and neurointensive care 1, 6

Common Pitfalls to Avoid

• Never administer nimodipine intravenously—this is a potentially fatal error 4
• Do not induce prophylactic hypervolemia or "triple-H therapy" (hypertension, hypervolemia, hemodilution) as this is not beneficial and may be harmful 1, 2
• Do not delay aneurysm treatment beyond 24-72 hours as rebleeding risk is highest early 1
• Do not use phenytoin for seizure prophylaxis 2
• Do not miss the diagnosis—maintain high suspicion for SAH in any patient with sudden severe headache, even if initial presentation seems benign 1, 7