Based upon initial neurologic examination in ED Samantha Higgins is in Grade 2 (severe headache,stiff
neck, no neurologic deficit except cranial nerve palsy) according to Hunt and Hess grading system for
Problem Lists:
...
Based upon initial neurologic examination in ED Samantha Higgins is in Grade 2 (severe headache,stiff
neck, no neurologic deficit except cranial nerve palsy) according to Hunt and Hess grading system for
Problem Lists:
Subarachnoid Hemorrhage
Migraine
History of HTN/Family Hx HTN (Mom)
History of Bell’s Palsy
History of Tension Headache
Status/Condition: Critical
Code Status: Full Code
Allergies: NKDA
Admit to Unit: ICU
Activity Level: Bedrest
Diet: NPO except medication
Critical Drips: None
Respiratory: 2L/NC titrate to RA keep O2 saturation >92%
Medications: Keppra, Labetalol, Tylenol, Morphine Sulfate, Colace
Lab Tests :
Diagnostic testing:
Head CT scan
Plan :
Subarachnoid Hemorrhage
- Labetalol 10 mg IVP Q8H PRN for SBP >160mmHg, hold if HR <60
-Administer Nimodipine 60mg PO Q4H – if permit by Neuro Surgeon (Singer, Olgivy, & Rordorf, 2019)
- Start on Keppra 1000mg IV now, then 500 mg IV Q8H for seizure prophylaxis
- Start IVF NS@100ml/hr – to maintain euvolemia
- Pain control – Tylenol 650mg PO PRN Q6H for mild pain and fever >101.3F, Morphine sulfate 2mg
IVP PRN Q4H for moderate to severe pain.
Hx ofMigraine/TensionHeadache
- Start on Keppra 500mg Q12H for seizure prophylaxis
- Start IVF NS@100ml/hr – to maintain euvolemia
- Pain control – Tylenol 650mg PO Q6H for mild pain. Morphine sulfate 2mg IVP Q4H for moderate to
severe pain.
History ofHTN/Family Hx HTN (Mom)
- Check BMP and Lipid panel
- Blood glucose daily
- Keep SBP between 120-160mmHg for cerebral perfusion
- Labetalol 10 mg IVP Q8H PRN for SBP >160mmHg, hold if HR <60
Hx ofBell’s Palsy
- Glucocorticoid – Start on prednisone 60mg PO daily - if permit by Neurologist
-Artificial tears
- PT/OT eval
Health Education and Maintenance
and required follow-up care:
- Routine follow-up of inpatients should be performed during each outpatient contact
- Monitor BP and pain at home and take medication as prescribed.
- Monitor depression, anxiety and sleep disturbance.
-Any changes in neurological status or level of consciousness call 911
References
Marcolini, E., & Hine, J. (2019). Approach to the Diagnosis and Management of Subarachnoid
Hemorrhage. The western journal of emergency medicine, 20(2), 203–211.
doi:10.5811/westjem.2019.1.37352
Singer, R., Olgivy, V., & Rordorf, G. (2019). Aneurysmal subarachnoid hemorrhage: Treatment and
prognosis. Retrieved from https://www.uptodate.com/contents/aneurysmal-subarachnoidhemorrhage-treatment-and-prognosis?csi=61fd0fbe-0bd5-43eb-835a52a9c09f6a5c&source=contentShare
Suarez, J.I. (2015). Diagnosis and Management of Subarachnoid Hemorrhage.Continuum (Minneap
Minn). 2015 Oct;21(5 Neurocritical Care):1263-87. doi: 10.1212/CON.0000000000000217.
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