Subarachnoid Hemorrhage

History * Sudden and maximal in onset* Compared to previous headaches* Family history of aneurysm* Associated Symptoms* Photophobia* Visual Changes* Neck Stiffness Exam * Full neuro examination* Cranial nerves* Visual fields* Speech* Cerebellar (finger-nose)* Motor* Sensation* Gait Testing Plan * Non-contrast head CT* Excellent sensitivity <6 hours from onset* Lumbar puncture* >100 RBCs in tube 4* Can be difficult to interpret after a traumatic lumbar puncture* Xanthochromia Treatment Plan * Prevent rebleeding* Keep SBP <140* Nicardipine* Reverse any anticoagulants* Vitamin K* Prothrombin complex concentrate* Fresh frozen plasma* Prevent vasospasm* Nimodipine PO* Prevent delayed ischemia* Avoid hyperthermia* Avoid hyper/hypoglycemia* Prevent seizures* Levetiracetam (aka Keppra) Additional Reading * Ottawa Subarachnoid Hemorrhage (MDCalc)