Download Subarachnoid Hemorrhage with aneurysym

Medical Surgical Nursing II
Subarachnoid Hemorrhage (SAH)

Description
 Bleeding into the
subarachnoid space
○ Rupture of a cerebral
aneurysm
○ Rupture of an
arteriovenous
malformation (AVM)
 Risk factors
○ Hypertension
○ Smoking
○ Alcohol and stimulant
use
2
MS II Neuro Presentation
Discuss the clinical presentation of
SAH as described in this case study

Assessment and
Diagnosis


 Clinical presentation
○ Abrupt onset of
headache / nausea /
vomiting / syncope /
neurological deficit
○ May cause loss of
consciousness /
coma or death


Sarah’s presentation
Sarah, a 42 year old
white woman was
seen in the
emergency
department after
collapsing at work.
Initially while at work
Sarah was
Confused
Incontinent of urine
MS II Neuro Presentation
3
Discuss the clinical presentation of SAH as
described in this case study

ER assessment
Cooperative
 Pupils equal/reactive
 Mildly disoriented
 Subjective: Headache unlike any she
had experienced before
 Duration 3 to 4 weeks prior to today
 Nausea – photophobia – nuchal
stiffness

How is SAH diagnosed?
Clinical presentation
 Non Contrast CT scan – cornerstone of
SAH diagnosis
 (95% of the cases CT can demonstrate
blood in the subarachnoid space if
performed within 48 hours of the
hemorrhage)
 LP is done if the initial CT finding is
negative

LP (Lumbar Puncture)



CSF fluid appears
bloody
RBC count is
greater than 1000
cells/mm#
If the LP is done five
days after the SAH
the fluid looks
xanthochromic
Cerebral angiography



Follows to identify
the exact cause of
the hemorrhage
Aneurysm if this is
the cause is located
It is then classified
Pathophysiology of SAH

Cerebral Aneurysm
 As cerebral aneurysm matures
○ Blood pressure rises
○ Stress placed on poorly developed and thin
blood vessel wall
 Most are saccular or berry-like
 Often occur in the circle of Willis at the
bifurcation of blood vessels
 Rupture of aneurysm sends blood into the
subarachnoid space
(continued)
Cerebral Aneurysm
FIGURE 18-1 Common locations of intracranial aneurysms. (From Goldman L, Ausiello D: Cecil medicine,
ed 23. St Louis, 2008, Saunders.)
Describe the consequences of
blood in the SA space
Blood is an irritant to the tissues
 Initiates an inflammatory response
 Cerebral edema
 Blood has decreased space in the
cranial vault
 Increases ICP
 Decreases CPP

What therapeutic modalities are
instituted after SAH
Sarah was admitted for the night. What
would her priority assessments be?
 Neurological check
 Pupils
 LOC
 GCS
 Vital Signs

What caused the differences in
Sarah’s GCS numbers





On arrival her score
was 14
Lethargic
Arouses to name
Cooperative
Oriented to person
only
Before surgery





Pupils equal and
reactive
Follows commands,
MAE =ly, equal hand
grips
Orientated to person
and place
Lethargic arouses to
name
GCS of 13
Apply the five major components
of neurological function to Sarah





LOC
Motor
Pupillary Function
Respiratory function
Vitals





Oriented to person
only day one day 2
oriented to person
and place.
Motor – moves all
extremities =ly
Pupils –
equal/reactive
Respiratory function
22 and 24
Vitals





Blood pressure day
one
152/78
What is the pulse
pressure?
Is her pulse
pressure elevated
Heart rate is 102
which is significant
for what stage of
ICP?



Day two
142/80
Heart rate 84
Medical Management of SAH
Early diagnosis—SAH is medical
emergency
 Goal is preservation of neurological
therapy

 Initial treatment
○ Support vital functions
○ Ventriculostomy to control intracranial pressure
(ICP) if the patient has decreased LOC

Rebleeding
(continued)
Rebleeding
Occurrence of a second SAH in an
unsecured aneurysm
 Less commonly AVM
 Rebleeding is most common within the
first _____hours but continues to be a
low risk for the following month
 Mortality 70% if it occurs
 Again – blood pressure control
individualized, avoid extremes

Treatment

Craniotomy for a clip
ligation of the left
inferior cerebellar
aneurysm.
Surgical Clipping
FIGURE 18-2 Clipping of a posterior communicating artery aneurysm. A, The solid curved line shows the
typical skin incision, and the dashed lines show the craniotomy location. B, Application of the clip to the
aneurysm.
Embolization
FIGURE 18-3 Endovascular occlusion of a posterior communicating artery aneurysm. A, Insertion of the
microcatheter into the aneurysm through the right femoral artery, aorta, and left carotid artery. B, Occlusion of the
aneurysm with coils.
Medical Management of SAH
(continued)
Surgical aneurysm clipping/surgical AVM
excision
 Embolization
 Cerebral vasospasm: Triple H Therapy

 Hypertensive/hypervolemic/hemodilution
 Oral nimodipine
 Transluminal cerebral angioplasty

Prevent complications of SAH
 Hyponatremia
 Hydrocephalus
Hypertensive/Hypervolemic/
hemodilution therapy
Used to treat cerebral vasospasm which
develops in 70% of patients with SAH.
 Diagnosed with cerebral antiography
 Onset is ____ to 12 days after SAH
 Sarah experiences this several hours
after surgery. What symptoms were
described?

Sarah’s Diagnosis of vasospasm
Was found with a CT scan of the head
which showed no rebleeding.
 This was followed with an arteriogram
which demonstrated narrowing of the
arteries.
 What was used to assess Sarah’s
response to the HHH therapy?

What is HHH therapy
Increasing the patient’s bp with
vasoactive medications and fluids
 Goal maintain bp between 150 and 160
systolic
 Rationale:
 Hemodilution:
 Rationale:

What vasoactive medications are used to
maintain blood pressure in this scenario
Dopamine 3 to 10 ug/kg/min
 Dobutrex 2.5 to 10 ug/kg/min
 Neo-synephrine
 To block vagal bradycardia which drug
would be used?

Complications of HHH therapy
Cerebral edema
 Increased ICP
 Cardiac failure
 Electrolyte imbalance

Nimodopine Therapy
Reduces poor outcomes associated with
vasospasm
 Dose 60 mg q4 hours for 14 to 21 days
 May produce hypotension
 Bp must be maintained in spite of this
drugs effects.

Hyponatremia
On arrival to the ER Sarah’s sodium was
130 mmol/L
 Develops in 10 to 43% of patients with
SAH – cerebral salt wasting syndrome
 Onset – Several days after the initial
hemorrhage
 Treatment – Isotonic fluids NS

Hydrocephalus
Late complication of SAH
 Blood that has circulated in the
subarachnoid space and has been
absorbed by the arachnoid villi may
obstruct the villi and reduce the rate of
CSF absorption
 Temporary solution – ventriculostomy
 Ventriculoperitoneal shunt.

Seizure Prophylaxis
Recommended for the SAH post
operatively
 Difference from stroke care
 What drug IV can be given for seizure
prophylaxis?
 Look this medication up.
 Know generic vs trade
 Possible side effects

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MS II Neuro Presentation