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Subarachnoid haemorrhage - Coggle Diagram
Subarachnoid haemorrhage
Causes
Aneurysms 85%
Anterior/anterior communicating 40%
MCA bifurcation 30%
Posterior communicating/internal carotid 20%
Basilar 4%
Areterio-venous malformations
Trauma
Trauma
Risks factors
Age - peak 40-60
Male x1.5
HTN
Athescerosis
Cocaine
EtOH XS
Smoking
Genetics
AD polycystic kidneys
Collagen eg Ehlers Danlos
Familial intracerebral anurysms
Management
Resuscitation
Airway
GCS <8
Drop in GCS >2 points
Optimising C02
Seizures
Facilitate transfer
Uncontrolled HTN in unsecured anurysm
Breathing
Pa02 >10
PaC02 4.5-5
Cardiovascular
SBP <160
MAP<110
SBP>100
Neuroprotective
Normothermia
normoglycaemia
30 degree head up
ETT taped
Neurosurgery
Secure rupture
Clipping vs coiling
Coiling < mortaility
Clipping > longevity
ISAT trial LAncet 2002
Avoid secondary brain injury
Obstructive hydrocephalus
Re-bleeding
Seizures
Vasospasm
Neuroloigcal deterioration lasting >1 hours
Peak incidence 4-10 days post SAH
Risk factors
smokers
high grade SAH
Large clot
Investigation
Transcranial doppplers
Flow velocities >120
Velocity increase >50
Lindegaard ratio >3
CT angiography
Overestimates
Digital subtration angiography
Gold standard
Treatment
Nimodipine 60mg 4 hourly for 21 days
Triple H
Hypertension
Haemodilution
Hypervolaemia
Magnesium sulphate
MASH-2 no benefit
Statins
STASH no benefit
Endovascular intervention
Grading
Wrodl Federation of Neurosurgeons
1 = GCS 15 no motor deficit
2 = GCS 13-14, no motor deficit
3 = 13-14, with motor deficit
4 = GCS 7-12
5 = GCS <6
Sodium balance
SIADH
Low osmoality serum
Evidence of euvolaemia
Low urine output
Sodium balance even
Cerebral salt wasting syndrome
Symptoms
Hypovaolaemia
Increased levels of ANP/BNP
Increased sympathetic tone
Hyponatraemia
renal loss of sodium
Polyuria
Diagnosis
<Na Serum
High osmolality serum
High urine osmolality
Urine sodium >40
Evidence of hypovolaemia
Management
Fluid resuscitation 0.9%
Hypertonic saline +/- furosemide
Fludrocortisone
Aldosterone antagonist
Monitor Hyperkalameia
Cranial DI