Subarachnoid Haemorrhage Re-bleed

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 

• 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 

• 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 

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