Subarachnoid Hemorrhage
EM Clerkship
Zack Olson, MD ; Mike Estephan, MD ; Maddie Watts, MD
4.9 • 816 Ratings
🗓️ 20 May 2018
⏱️ 9 minutes
🧾️ Download transcript
Summary
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)
Transcript
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| 0:00.0 | Hello, med students. My name is Zach Olson and thank you for downloading this week's |
| 0:07.0 | episode of the EM Clerkship Podcast. Here's your case. |
| 0:19.2 | Okay, everybody, we've got a 43-year-old male. |
| 0:21.6 | Had a sudden onset of headache about an hour ago, 10 out of 10 on the pain states he feels like he got kicked in the head. |
| 0:28.6 | No trauma, emesis times two, slight isolated right pupil dilation and sluggish to reflex to light. |
| 0:35.6 | No history, no meds, no allergies, 180 over 90, pulse of 120, respiration is 20, 98% and 156 on the glucose. |
| 0:43.3 | Any questions? |
| 0:45.3 | Yeah, wife is waiting room. |
| 0:49.3 | Okay, thank you. |
| 0:51.3 | All right, what's your differential? Thank you. |
| 0:55.7 | All right. |
| 0:57.2 | What's your differential? |
| 1:04.1 | When a patient presents like this, I have a few things in mind myself. |
| 1:09.0 | Menagitis, strokes, maybe like a vascular dissection, |
| 1:14.9 | but one of the most important things on my differential is subarachnoid hemorrhage, |
| 1:21.1 | that sudden and severe headache, the king of bad headache causes. |
| 1:29.5 | These are usually caused by an aneurism on the circle of Willis that leaks or breaks open, |
| 1:34.7 | that blood floats around in the subarachnoid space, irritating the brain and then eventually settling into those cisterns. |
| 1:37.2 | And it's just really not good. |
| 1:39.4 | These patients don't do well. |
| 1:41.8 | Risk factors are family history, smoking, a few other things, plus that |
| 1:46.7 | worst risk factor of all, bad luck. And so that's what we're going to talk about this week, |
... |
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