Subarachnoid Haemorrhage Re-bleed

Published 03/08/2022

Subarachnoid Haemorrhage Re-bleed




RIJ CVC, left radial arterial line, single peripheral cannula 


Sedatives (propofol & opiate), 1L crystalloid 100mls/hr  




V-SIMV 500/8 FiO2 0.5 Rate 14 breaths/min 


EVD (transduced and clamped) 

Clinical Setting

I:       You are the ICU registrar called to see a new admission who is hypertensive 

S:      Bedside nurse would like some hydralazine prescribed as the patient isn’t meeting their blood pressure targets.  

B:      44F recent arrival from St. Elsewhere with a SAH. Been to theatre for EVD insertion. 

A:     Hypertensive, sedated and ventilated. SBP targets of 120-160mmHg 

R:     Called you for assistance 

Potential Clinical Course

  • Initially A ETT with ties, B RR 10, SpO2 98% on FiO2 0.50, EtCO2 6.1kPa, clear chest to auscultation, C HR 94bpm SR, BP 176/88, D Sedated propofol/fentanyl, coughs on suctioning, EVD set at 15cm, ICP 20mmHg pupils equal E nursed flat 
  • ICP begins to climb, eventually peaking at 38mmHg with appropriate ICP trace 
  • Pupils remain equal, but sluggish 
  • Sits patient up, removes ties 
  • Gives bolus of sedation, and increases sedation rates 
  • Gives dose of NMBD 
  • ICP number remains high, one pupil blows, then second pupil blows 
  • Patient becomes very hypertensive and bradycardic 
  • Gives osmotic diuretic 
  • Examines EVD – clamped. Unclamps. 
  • Pupils improve, bradycardia improves and hypertension improves 
  • Calls neurosurgery and hands over patient 

Information for Faculty

  • Initial Settings: RR 10 
  • SpO2 98% on FiO2 0.50 
  • EtCO2 6.1kPa 
  • Clear chest  
  • HR 94bpm SR 
  • BP 176/88 
  • ICP 21mmHg 
  • Pupils equal but sluggish 


  • Progress to: RR – whatever the candidate changes it to 
  • SpO2 98% on FiO2 0.50 
  • EtCO2 4.5kPa – slowly over 2 mins after RR/VTe increased on vent 
  • HR 88bpm SR 
  • BP 156/77 – on increasing sedatives 
  • ICP 28mmHg 
  • Left pupil 3mm/ Right pupil 5mm - sluggish 


  • Progress to: EtCO2 3.8kPa 
  • ICP 38mmHg – slowly over 3 mins 
  • BP 168/82 
  • HR 72bpm SR 
  • Left pupil 3mm/Right pupil 5mm – sluggish 


  • Progress to: EtCO2 3.6kPa 
  • ICP 47 – over 30 seconds  
  • BP 204/112 – over 2mins 
  • HR 43bpm SR – over 2mins 
  • “Blow” one pupil, then the other 


  • Once rescue therapy given: osmotic diuretic/thiopentone bolus/EVD unclamped: 
  • BP 153/76 
  • HR 77bpm SR 
  • Left pupil 3mm/Right pupil 5mm - sluggish 

Faculty Roles

Bedside Nurse 1: 

  • You are thrilled that this is the first patient you are caring for unsupervised since starting on the unit 
  • You have just received the patient from the theatre team – you know that she has had a subarachnoid haemorrhage and has been transferred under neurosurgery for a DSA and coiling in the morning. Her SBP targets have been set at 120-160mmHg, and she is currently exceeding that 
  • You suggest some hydralazine 



Bedside Nurse 2: 

  • You only arrive when called for by the registrar/nurse for assistance 
  • You are a senior critical care nurse 
  • You take direction well, but lack impetus 
  • When you arrive, if the candidate is not coping well, address the targets written on the “Daily Plan” on the bedside chart 


HiLLO: 5, 12