Emergency Department · CCS Case Walkthrough

Headache — Subarachnoid Hemorrhage

45-year-old female presents with sudden-onset "worst headache of my life," stiff neck, photophobia, and one episode of vomiting. Symptoms began 2 hours ago during exercise.

Step-by-Step Approach

  1. Stabilize — assess ABCs, check neuro status (GCS), vitals
  2. Stat non-contrast CT head (sensitivity ~95% within 6 hours)
  3. If CT negative but suspicion high — lumbar puncture (xanthochromia)
  4. If SAH confirmed — CT angiography to locate aneurysm
  5. Consult neurosurgery immediately
  6. Nimodipine 60 mg q4h PO (prevents vasospasm)
  7. Maintain SBP < 160 with IV labetalol or nicardipine
  8. ICU admission, neuro checks q1h, seizure precautions
  9. Stool softeners (avoid Valsalva), pain management (avoid NSAIDs)

Common Orders Checklist

✓Non-contrast CT head (stat)
✓CT angiography
✓CBC
✓BMP
✓PT/INR
✓Type and screen
✓Nimodipine 60 mg q4h
✓Labetalol or nicardipine IV
✓Neurosurgery consult
✓ICU admission
✓Neuro checks q1h
✓Seizure precautions
✓HOB elevation 30 degrees
✓Stool softener
✓Acetaminophen for pain (avoid aspirin/NSAIDs)

Common Pitfalls

  • ⚠Ordering CT with contrast instead of non-contrast — contrast obscures blood
  • ⚠Skipping LP when CT is negative but clinical suspicion is high
  • ⚠Giving aspirin or NSAIDs (increases bleeding risk)
  • ⚠Forgetting nimodipine — it reduces vasospasm-related morbidity
  • ⚠Not controlling blood pressure urgently — re-bleed risk is highest in first 24h

Related Topics

Ischemic StrokeMeningitisHypertensive Emergency
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