Subarachnoid Hemorrhage: Therapy

General measures

• Bed rest
• Pressor acts (vomiting, defecation) should be avoided → use of antiemetics (anti-nausea and anti-vomiting pharmaceuticals), laxatives (laxatives) if necessary.
• Securing or stabilization of vital functions (respiration, body temperature, circulation) – intubation in case of GCS* ≤ 12 or respiratory insufficiency (inability of the lungs to absorb sufficient oxygen from the ambient air into the blood)
• Nicotine restriction (refraining from tobacco use).
• Limited alcohol consumption (men: max. 25 g alcohol per day; women: max. 12 g alcohol per day).

* Glasgow Coma Scale (GCS): scale for estimating a disorder of consciousness (see “Classification”).

Monitoring

To detect complications such as vasospasm (spasmodic constriction of a blood vessel) or hypovolemia (volume deficiency) early, the patient should be observed on a monitoring unit or receive intensive medical care. The following parameters are monitored:

• Respiration
• Blood pressure – elevated blood pressure levels promote rebleeding and/or increase the risk of rupture
  • Until the aneurysm is supplied, the mean arterial blood pressure (MAD; mean value of the blood pressure curve over time) should be 60-90 mmHg
  • Target range for normotensive patients: 120-140 mmHg.
  • Target range for hypertensive patients: 130-160 mmHg
• Heart rate
• Blood clotting
• Neuroprotection (protection of nerve cells):
  • Blood glucose (blood sugar) → normoglycemia (blood sugar levels within the normal range).
  • Electrolytes, fluid balance → avoidance of hyponatremia (sodium deficiency) and hypovolemia (volume deficiency).
  • Body temperature → avoidance of fever
• Measurement of central venous pressure (CVP engl. central venosus pressure).
• Transcranial Doppler sonography (ultrasound examination through the intact skull for orienting control of cerebral (“concerning the brain“) blood flow; brain ultrasound) – daily.
• Urine output

Airway management – for decreased vigilance (attention).

• Pulse oximetry-measured oxygen saturation (SpO2) should be >90%.
• Patients with severe sepsis/septic shock should be ventilated early.
• The following parameters should be adhered to:
• Controlled ventilation:
  • Tidal volume (breath volume, or AZV; is the set volume applied per breath): 6 ml/kg standard body weight
  • Plateau pressure (measure of end-inspiratory pressure in alveoli in a flow-free phase): < 30 cm H2O.
  • Oxygen saturation (SpO2): > 90%.
• PEEP (engl. : positive end-expiratory pressure; positive end-expiratory pressure) as a function of FiO2 (indicates how high the O2 content in the breathing air is).
• In severe oxygenation disorders, prone positioning or 135° positioning should be performed.
• Weaning (English : to wean; or ventilator weaning is the phase of weaning a ventilated patient from the ventilator) should be started as soon as possible.

Notes on fitness to drive after subarachnoid hemorrhage

Legend

• Group 1: passenger cars, trucks up to 3.5 t, passenger cars plus trucks up to 3.5 t.
• Group 2: buses, trucks > 3.5 t, buses + trucks > 3.5 t

Rehabilitation

• Physiotherapy
• Speech therapy
• Occupational therapy