[##]-year-old [male/female] presents with [headache/altered
mental status] with history and exam consistent with likely subarachnoid
hemorrhage (SAH).
Initial considerations in this patient included SAH from ruptured
aneurysm, non-aneurysmal bleeding, and trauma, epidural and subdural
hemorrhage, intracranial mass, cerebrovascular accident (CVA), transient
ischemic attack (TIA), meningitis, encephalitis, and cerebral venous thrombosis
among others.
Patient presented [within 6/12/24 hours] of onset of
headache concerning for SAH. Patient noted
to have associated [neuro deficits/nuchal rigidity]. CT scan obtained [with/without] clear
evidence of SAH. A lumbar puncture [was
not performed due to clear evidence of SAH on CT/was performed with evidence of
xanthochrmia consistent with SAH/was not performed due to patient refusal/was
unsuccessful prompting us to obtain CT angiogram]. Patient was noted to have a Hunt & Hess
Grade [I-V] score as noted above on presentation to the ED. Patient noted to have [no] history of [anticoagulant
or antiplatelet/anticoagulant/antiplatelet] use with [no indication for reversal/reversal
of Coumadin initiated with prothrombin complex concentrate (Kcentra)/fresh
frozen plasma (FFP) and vitamin K/reversal of Aspirin initiated with DDAVP/reversal
of Plavix initiated with platelets/reversal of Dabigatran (Pradaxa) initiated
with Idarucizumab (Praxbind)].
Patient was intubated [due to respiratory failure/evidence
of inability to protect there airway] as noted above.
Patient noted to be hypertensive on presentation with
[some/minimal] improvement noted with administration of analgesics. Despite absence of clear consensus
recommendations on blood pressure control in the setting of SAH, we initiated treatment
with [Nicardipine/Labetalol/Esmolol] with a goal systolic blood pressure of
less than 160 mmHg [after consultation with neurosurgery].
Patient noted to be hypotensive on presentation with [IV
fluids given/IV fluids and vasopressors initiated] to maintain a goal mean arterial
pressure of greater than 80 mmHg.
Patient given Nimodipine via [oral route/NG/OG
tube] to decrease incidence of delayed cerebral ischemia. Seizure prophylaxis initiated in the ED with
[Keppra/etc.]. Case discussed with Dr. [NAME] the neuro-interventionalist with plan to [admit/transfer] for endovascular [intervention/clipping/coiling]. We discussed concern for SAH and plan for admission with the [patient/family] with associated risks and benefits, and they demonstrated understanding and agreement with this plan and provided appropriate consent.
https://wikem.org/wiki/Subarachnoid_hemorrhage
https://emcrit.org/emcrit/sah/
https://www.mdcalc.com/hunt-hess-classification-subarachnoid-hemorrhage#use-cases
