SAH Not Intubated

Impression:

Acute Subarachnoid Hemorrhage:
- Hunt and Hess: *** mFG: ***
- Day of admission: ***
- Etiology: ***

Plan:

Neurological:
- Neurological checks q1h
- Seizure, fall, aspiration precautions
- Head of bed at 30 degrees at all times
- SBP goal 100-140 (not secured yet)
- Neurosurgery managing EVD
- CTH/CTA:
- No free water, mix everything in NS as this can worsen cerebral edema
- PT/OT/ST consults initiated
- TCD will be done daily
- Meds:

1. Nimodipine 60mg PO q4h
2. APAP 500 mg PO q6h PRN for pain or headache

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Respiratory:
- Aspiration precautions, head of bed above 30 degrees
- PRN O2
- Baseline CXR
- Meds:

1. ***

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Cardiology:
- Continuous cardiac telemetry
- SBP goal 100-140 (source of bleeding is unsecured yet)
- TTE for baseline EF (to guide IVF, cardene and pressor therapy if required)
- Meds:

1. Nicardipine drip (target SBP < 140)
2. Labetalol 10mg IV q4h prn

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Renal:
- Renal function normal
- Monitor electrolytes daily
- Avoid hypotonic fluids as this can worsen cerebral edema
- Meds:

1. NS @ 75ml/h

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Gastrointestinal:
- NPO for now till speech evaluation
- Last BM: unknown
- Meds:
1. Docusate 100 mg PO TID
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Endocrinology:
- FSBS q6hr while NPO
- Check HgbA1c, TSH
- Meds:

1. Insulin SS q6h while NPO then ACHS
2. Hypoglycemia protocol

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Hematology:
- Monitor CBC daily
- SCDs for prophylaxis; no heparins given acute subarachnoid bleed
- Meds:

1. None

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Infectious Disease:
- Current access: PIVs (placed), will place PICC line
- Keep normothermic, aggressive fever control as it worsens neurological outcomes
- Meds:
​      1. APAP 500mg q6hr PRN for fever >38.3

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Prophylaxis:
DVT: SCDs, no anticoagulation in the setting of recent subarachnoid bleed
GI: docusate
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Consults:
Neurointervention
Neurosurgery
Physical therapy
Occupational therapy
Speech therapy
Nutrition
Case Management
Social Work
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Discharge Planning:
Patient requires ICU level of care for monitoring of potential complications of SAH (rebleeding, vasospasm, hydrocephalus)