Early Critical Care Management of Aneurysmal SAH

• 30,000 patients per year have an SAH
• Early ED management certainly should focus on airway assessment, emergent CT scanning, continuous caridac monitoring, and serial neurologic exams
• A few other pearls regarding management:
  • Volume management - maintain euvolemia with an isotonic crystalloid fluid
  • Anticonvulsants - routine use is associated with cognitive impairment and is not recommended
  • Steroids - once used to reduce meningeal irritation, however, there is no convincing evidence of a beneficial effect.  As such, corticosteroids are no longer recommended.
  • Rebleeding - risk of rebleeding is highest in first 24 hours after initial SAH.  Definitive prevention is done by repair via surgery or endovascular coiling.  A large, prospective study found outcome was better with endovascular coiling.

References

Diringer MN. Managment of aneurysmal subarachnoid hemorrhage. Crit Care Med 2009;37:432-40.