Initial patient management

It is estimated that 10-15% of SAH victims die before reaching the hospital. Patients who survive the acute phase of SAH face many hazards that can lead to additional mortality and morbidity. The treatment of choice for a ruptured cerebral aneurysm is surgery; however, skillful medical and nursing care provides the patient with the best chance of recovery while a decision about surgery is made. Management of suspected SAH during the first few hours is critical.

Early Nursing Management:

• Assess airway, breathing, and circulation
  • O2 saturation
  • Anticipate rapid sequence intubation
  • Suction
  • Monitor EKG - post hemorrhage catecholamine release can cause myocardial ischemia, seen as abnormal S-T and/or QRS
  • pCO2 30-35 mm Hg - hyperventilation may induce vasospasm
• Neuro assessment:
  • Level of consiousness
  • Glascow Coma Scale
    • Eye opening response
    • Motor response
    • Verbal response
• Physical Assessment
  • Signs of trauma
  • Nuchal rigidity
• Headache
• Kernig's, Brudzinski's
• Paralysis
• History
  • Loss of consciousness
  • Seizures
  • Recent sudden severe headache (sentinel)
  • N/V
  • Visual disturbances
• Prepare patient for
• IV access
• CVP
• Arterial pressure monitoring
• ICP monitoring
• EKG
• Blood tests
• CT/MRI/MRA
• Anticipate orders for:
  • Calcium channel blocker nimodipine, to prevent vasospasm
  • Analgesics and sedatives as needed (avoid over sedation)
  • Anticonvulsant therapy
  • Surgery - NPO

Following initial stabilization, the treatment regimens include the following strategies:

• Aneurysm precautions
  • Complete bed rest (Reading, watching television, and listening to music are
    permitted, provided they do not overstimulate the patient)
  • Prevent Valsalva maneuver (straining at stool, coughing, antiemetics)
  • Administer care gently
    • reposition one movement at a time
  • O2, suction available
• Blood pressure management (avoid hypotension)
  • CVP 8-12 mm Hg, or PCWP, 12-16 mm Hg
• ICP management
  • elevate HOB 30 degrees
  • monitor ICP
  • Ventriculostomy drains, shunt
  • mannitol
  • stool softeners
  Pain management and sedation
• Drug therapy to prevent vasospasm.
  • Nimodipine within 96 hours of SAH for 21 days
  • Hyperdynamic therapy (triple H) post-op to increase perfusion
    • induced hypertension
    • hemodilution
    • hypervolemia
  • I/O - dehydration associated with vasospasm
  Embolus prevention
  • elastic hose
  • sequential compression boots.
  Seizure precautions
  • O2, suction available bed in low position
  • Side rails up and padded
• Continuous monitoring of neurological signs, changes may indicate rebleed or vasospasm

The nurse plays a pivotal role in monitoring the patient with SAH for signs of early complications and in implementing the medical regimen.