Review of SAH for ICU nurses.

1. Subarachnoid Hemorrhages

2. Subarachnoid Hemorrhage
• Subarachnoid hemorrhage (SAH) is
bleeding into the subarachnoid space.
• SAH may occur spontaneously from an
aneurysm or from head trauma.
• Mortality from SAH are very high (10%
die before the hospital, 25% with 24
hours & 45% with 30 days)Stroke 1994;25(7)1342

3. Subarachnoid Hemorrhage
• Signs and Symptoms of a SAH:
• Headaches
• Photophobia
• Nausea & Vomiting
• Seizures
• Decreased LOC
• Neurological Deficits
• Stiff Neck
• Seizures

4. Subarachnoid Hemorrhage
• The Hunt & Hess Classification grades the severity SAH based
on the patient’s clinical condition:

5. Subarachnoid Hemorrhage
Why are SAH so deadly?
• Hydrocephalus
• Rebleeding
• Vasospasms & Delayed Cerebral Ischemia
• Elevated ICP
0
20
40
60
First Hour First Day 30days

6. Subarachnoid Hemorrhages
• Hydrocephalus develops in 20 to 30% of
SAH patients. Stroke 2009;40(3)994
• Communicating hydrocephalus, the
type seen after SAH, occurs when CSF
cannot be absorbed normally through
the arachnoid villi.

7. Subarachnoid Hemorrhages
• 4% of patients
rebleed in the first
6 hours.
• 20% of patient
rebleed within 14
days.
• Rebleeding is
catastrophic (80%
mortality rate)

8. Subarachnoid Hemorrhages
• Vasospasms occur in 40-60%
of SAH patient.
• 20-30% of vasospasm
patients develop delayed
cerebral ischemia (DCI).
• Some patient develop DCI
without vasospasm.
• Pathogenesis of vasospasm
and DCI not fully
understood.

9. Subarachnoid Hemorrhages
+ +
80% 10% 10%
• The skull is rigid and can not expand.
• Volume = Brain (80%) + blood (10%) + CSF (10%).
• Increased volume within the skull will increase the ICP.
• Normal ICP is 10 – 20 mmHG
• Cerebral edema, blood, and hydrocephalus may caused an elevated ICP
(<20mmHg)
• Elevated ICP worsens outcomes

10. Subarachnoid Hemorrhage
• SAH is bleeding into the subarachnoid space
• The Hunt & Hess Classification grades the
degree of neurological deficits
• Grade I (mild deficits + mortality) → Grade V
(severe deficits + mortality)
• SAH patients have a substantial mortality
rate from hydrocephalus, rebleeding,
increased ICP & delayed cerebral ischemia
(vasospasms)
• Early, the risk of bleeding is higher. Later,
the risk of vasospasms increases (see next
slide).

11. Subarachnoid Hemorrhage
Vasospasm 0 to 21 days
❶Vasospasm can develop up to 3 weeks.
❷Highest prevalence between 7 and 21 days.
❸Vasospasms may not cause neurological deficits.
❹Pathogenesis of vasospasm is not fully understood.
❺Delayed Cerebral Ischemia results in new neurological
deficits.
Rebleeding 0 to 14 days
Highest risk in the first 6
hours
❶ Early surgical repair (day 1 to 3: clipping or coiling)
reduces the risk of rebleeding.
❷ Careful BP control reduces the risk of rebleeding.
Highest risk of vasospasm from 7 to 21 days

12. Subarachnoid Hemorrhage
• VS Q1H
• NVS as ordered
• Temperature Q4H + PRN
• Zero ICP Monitor Qshift + PRN
• ICP + CPP Q1H + PRN
• CSF Drainage Q1H
• ABG Qshift + PRN
• HOB 30degrees
Next, lets get more
specific:

13. Subarachnoid Hemorrhage
❶Hydrocephalus Management
❷Blood Pressure Control
❸Early Surgical Management (clipping or coiling)
❹Hypertensive Therapy
❺Nimodipine Therapy
❻Temperature Control
❼Seizure Control
❽ ICP Management
❾Pain / Nausea Control

14. Subarachnoid Hemorrhage
• Hydrocephalus is a frequent
complication of a SAH.
• EVD are inserted to drain excessive CSF
and to monitor ICP.
• Initially, CSF is bright red but slowly
becomes yellow (xanthochromia).
• Nursing Care:
• NVS as ordered
• Q1H ICP Monitoring
• Q1H CCP Monitoring
• Q1H CSF Drainage Output
• Qshift Zero EVD
• Ensure collection chamber is at the
correct height (cmH20 or mmHg)
• Level EVD PRN

15. Subarachnoid Hemorrhage
• BP should be kept between 120 to 160mmHg
• BP goal set by Neurosurgery Team
• Hypertension increases the risk of rebleeding
Stroke 2009;43:1711-37
• Aggressive BP management (too low) increases
the risk of infraction Stroke 2012;43: 1711-37
• Nursing Care:
• NVS
• Q1H BP (and PRN)
• Minimize stimulation
• Prevent emesis
• Pain Control
• Medication PRN

16. Subarachnoid Hemorrhage
• Typically, the aneurysm is secured
within the first 3 days (coiling or
clipping depending upon type of
aneurysm and location).
• Reduces the risk of rebleeding.
• Allows more aggressive
management of vasospasm and
delayed cerebral ischemia.

17. Subarachnoid Hemorrhage
• Hypertensive therapy is utilized to combat
vasospasms.
• Vasospasm can cause cerebral ischemia and
neurological deficits.
• Levophed (as well as Milrinone) is used to
increase BP which preserve cerebral blood flow
and prevent ischemia.
• In extreme cases, endovascular rescue
therapies (balloon dilation and intra-arterial
medications) may be attempted.
• Nursing Care:
• NVS as ordered
• Ensure BP parameters are achieved

18. Subarachnoid Hemorrhage
• Nimodipine, a calcium channel blocker
used to help prevent vasospasms
induced cerebral ischemia
• Mechanism of action of Nimodipine
not fully understood. N England Journal of Medicine
1983;308:619-624
• Nursing Care:
• NVS as ordered
• Administer Nimodipine as orders (60mg Q4h
or 30mg Q2H)
• Monitor carefully for neurological deficits
• Monitor BP closely (may cause hypotension)

19. Subarachnoid Hemorrhage
• Neurogenic Hyperthermia is
common in SAH (41-71%) Neurosurgery 2010;
66:696-700
• Normothermia improved
outcomes.
• Nursing Care:
• Temperature Q4H & PRN
• Cooling as ordered
• Tylenol as ordered

20. Subarachnoid Hemorrhage
• During hospitalization, 5% of
SAH patients, will have
seizures.
• Anticonvulsant therapy may be
indicted in these patients.
• Nursing Care:
• NVS
• Monitor for seizure activity
• Administer anticonvulsants and
benzodiazepines as ordered.

21. Subarachnoid Hemorrhage
• Elevated ICP will result in a
poor neurological outcome.
• Draining CSF can lower ICP.
• Nursing Care:
• NVS as ordered
• Q1H + PRN ICP & CPP
• Sedation
• HOB 30 degrees
• PaCo2 between 35-45 mmHg

22. Subarachnoid Hemorrhage
• Severe headaches are common in
SAH.
• Pain control is essential for patient
comfort.
• Excessive pain may cause
unwanted hypertension.
• Nausea and emesis is common
with SAH patients
• Administer antiemetic
medications, as ordered, to
prevent vomiting.
• Vomiting increases the risk of
rebleeding, and increases ICP.

23. Subarachnoid Hemorrhage
• Rebleeding is an early and catastrophic
complication of SAH.
• Early aneurysm repair reduces the risk of
rebleeding.
• EVD are inserted to drain excessive CSF and to
monitor ICP.
• Nimodipine Therapy is used to mitigate
vasospasm, and to prevent cerebral ischemia.
• Once the aneurysm is secured Hypertensive
Therapy is used to prevent cerebral ischemia.
• Careful neurological assessment is essential.

24. Subarachnoid Hemorrhage
Thank you….
References:
https://www.youtube.com/watch?v=
WNcGiM5kH5s
Stroke 1994; 25(7) 1342
Stroke 2009; 40(3) 994
Stroke 2012; 43:1711-37
NEJM 1983; 308:619-624