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SAH
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Background Subarachnoid hemorrhage entrains a number of phsyiologic changes that can be very destructive (ischemia, infarction) to the brain. Blood within the subarachnoid space. Specific procedure and protocol pertains to spontaneous (nontraumatic) subarachnoid hemorrhage as this may be the result of bleeding from ruptured cerebral aneurysms or arteriovenous malformations. Appropriate diagnosis of vascular etiologies of hemorrhage is important as specific treatments to prevent
re-bleeding and vasospasm are necessary to reduce morbidity and mortality.
Subarachnoid hemorrhage (SAH) is a common 5036 Admission Diagnosis.
In adults the most common etiology (cause) of an subarachnoid hemorrhage is rupture of a congenital berry aneurysm.
Inclusion criteriaPatients with vascular sources of spontaneous subarachnoid hemorrhage present characteristically with “the worst headache of their life.” Based on this initial history, an aggressive work-up should seek to identify hemorrhage based on radiographic (CT) and laboratory (lumbar puncture) data. Exclusion criteriaPatients with clearly identified traumatic sources of bleeding, not including those patients who had trauma due to a primary alteration in mental status (e.g.: motor vehicle accident as a result of spontaneous loss of consciousness)
Annual risk of rupture
Location Patients with subarachnoid hemorrhage should be transferred to an intensive care unit setting for close observation and hourly neurologic checks. Deterioration can occur as a result of rehemorrhage, vasospasm, or hydrocephalus. EquipmentStandard intensive care unit monitoring should be available. Transcranial doppler should be available to monitor changes in the cerebral vasculature, facilitating the early detection of vasospasm. ProcedureNo specific procedures need be performed in all patients. However, swan-ganz monitoring of cardiac parameters, arterial line monitoring, intubation, and ventriculostomy placement may all be necessary. Surgeon QualificationsPatients with subarachnoid hemorrhage from aneurysmal or arteriovenous malformation rupture should be kept in an intensive care unit setting. Neurosurgical input in the management of these patients is essential. Neurology or critical care medicine specialists may also offer input in management. Complication ManagementWell-described sequelae of subarachnoid hemorrhage include:
Orders Inclusion CriteriaPatients with vascular sources of spontaneous subarachnoid hemorrhage present characteristically with “the worst headache of their life.” Based on this initial history, an aggressive work-up should seek to identify hemorrhage based on radiographic (CT) and laboratory (lumbar puncture) data. Exclusion CriteriaPatients with clearly identified traumatic sources of bleeding, not including those patients who had trauma due to a primary alteration in mental status (e.g.: motor vehicle accident as a result of spontaneous loss of consciousness)
Blood pressure results from the energy put into the blood with each contraction of the heart. This energy moves the blood forward (towards the veins and right ventricle) against the resistance of arteries that generate their resistance through the smooth muscles that line their walls.
Spasm of an artery that results from injury to the vessel. During insertion of an arterial line probably results from one or both: 1. mechanical contact between the a-line needle and the arterial wall causes smooth muscles to constrict and narrow the vessel sometimes to the point that there is no flow and frequently to the point that a pulse is no longer palpable and further attempts at aterial puncture and cannulation will be futile.
Test to make sure it is safe to place a catheter in the radial artery at the wrist.
Technique: Compress the radial artery firmly enough that that there is no flow through it. Hold for several minutes observing for ischemic changes in the hand.
Reason to do test: if inadequate collaterals through ulnar arterial arcade, hand will become dusky and cold.
The radial artery is located on the same side of the hand as the thumb.
(The femoral artery should only be used for placement of an arterial line if cannulation of the radial artery is impossible).
Nerve, Artery, Vein...
1. Real time, continuous measurement of arterial blood pressure 2. Sampling of arterial blood
Duration: An arterial line should be left in place no longer than 5 days. Replacement:
If an arterial line has been in so long (5 days) that it must be
replaced, the replacement line should not be placed in the same artery as
the original.
Post-graduate year (PGY) 2 or higher.
Required if a next-of-kin available.
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Orders (routine, without complications):
Hypervolemic, Hyperdynamic, Hypertensive: Hypervolemic Increasing the intravascular volume Hyperdynamic Forcing the heart to contract harder Hypertensive Raising the blood pressure
EvaluationPatients with an appropriate history of acute onset of headache or meningismus should first receive a noncontrast head CT scan. If this shows no hemorrhage, lumbar puncture should be performed in an effort to identify xanthochromia or a large number of red blood cells. Those patients with proven subarachnoid hemorrhage should then receive either four vessel cerebral angiography or magnetic resonance angiography (MRA). CT also serves to identify early hydrocephalus. LocationPatients with subarachnoid hemorrhage should be transferred to an intensive care unit setting for close observation and hourly neurologic checks. Deterioration can occur as a result of rehemorrhage, vasospasm, or hydrocephalus. EquipmentStandard intensive care unit monitoring should be available. Transcranial doppler should be available to monitor changes in the cerebral vasculature, facilitating the early detection of vasospasm. ProcedureNo specific procedures need be performed in all patients. However, swan-ganz monitoring of cardiac parameters, arterial line monitoring, intubation, and ventriculostomy placement may all be necessary. Surgeon QualificationsPatients with subarachnoid hemorrhage from aneurysmal or arteriovenous malformation rupture should be kept in an intensive care unit setting. Neurosurgical input in the management of these patients is essential. Neurology or critical care medicine specialists may also offer input in management.
Background - Epidemiology - Pathophysiology - Presentation - Workup - Management - Complications The equipment required to insert a Swan-Ganz catheter includes:
The equipment
required to insert a Swan-Ganz catheter includes: Complication Management
Well-described sequelae of subarachnoid hemorrhage include:
Protocol for management Orders (routine, without complications):
Vasospasm
The history of a subarachnoid hemorrhage is classically "the worst headache of my life".
Patients with an appropriate history of acute onset of headache or meningismus should first receive a noncontrast head CT scan. If this shows no hemorrhage, lumbar puncture should be performed in an effort to identify xanthochromia or a large number of red blood cells. Those patients with proven subarachnoid hemorrhage should then receive either four vessel cerebral angiography or magnetic resonance angiography (MRA). CT also serves to identify early hydrocephalus.
Post-graduate year (PGY) 2 or higher. Post-graduate year (PGY) 2 or higher. Required if a next-of-kin available. Self-assessment
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