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A 49-year-old man with history of hypertension and hyperlipidemia presents with a sudden onset of severe bifrontal headache followed by nausea. The headache, the worst headache he had ever experienced, came on suddenly. The patient vomited on his way to the nearby emergency department (ED) and became obtunded in the ambulance. On arrival to the ED, he was intubated for airway protection as his mental status continued to worsen. About 30 minutes after the onset of the initial symptoms, he progressed to stuporous mental status. He was able to flex his elbows bilaterally to painful stimulation. Brainstem reflexes were all intact. Stat head computed tomography (CT) (Figure 1-1) revealed acute subarachnoid hemorrhage (SAH) filling the basal cistern, bilateral sylvian fissures with thick hemorrhages along with early radiographic evidence for hydrocephalus, and intraventricular hemorrhage (IVH) mainly in the fourth ventricle. The local ED physicians decided to transfer the patient immediately to the nearest tertiary medical center. During the emergent transfer, patient stopped responding to any painful stimuli and had only intact brainstem reflexes.

On arrival at the neuroscience intensive care unit (NeuroICU), the following is the clinical observation: Patient is intubated with endotracheal tube, is in coma, decerebrate posturing to painful stimulation, has intact corneal reflexes, pupils 5 mm in diameter briskly constricting to 3 mm bilaterally to light, intact oculocephalic reflexes, and positive bilateral Babinski signs.

Vital signs on arrival to the NeuroICU: heart rate, 110 bpm in sinus tachycardia; respiration rate, 20 breaths per minute on the set rate of 14 breaths per minute on assist control–volume control mechanical ventilation; temperature, 99.3°F; and blood pressure (BP), 190/100 mm Hg by cuff pressure.

What are the initial steps for resuscitating acute aneurysmal SAH in this case?

ABC and EVD. You must optimize cerebral perfusion pressure (CPP) for all poor-grade SAH

The clinical and radiographic presentation of this case is consistent with poor grade (initially Hunt and Hess [HH] grade IV, which quickly progressed to grade V while in transit to the tertiary care center) acute aneurysmal SAH. Airway, breathing, and circulation (ABC) have all been addressed, although the BP is high at this time. The very first step in managing this patient is ventricular drain, the second step is ventricular drain, and the third step is ensuring that the ventricular drain you have just placed is working (ie, draining bloody cerebrospinal fluid [CSF] adequately when the drain is open, and maintaining good waveforms when the drain is clamped). After ABC, placing external ventricular drain (EVD) is the most crucial, lifesaving, important early ...

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