A 46-year-old man comes to the emergency department complaining of severe headache for the last 3 hours. He took ibuprofen without much relief. He suffers from tension headaches but says that this headache is nothing like those. He feels nauseated and wants to move to a quiet, dark room.
His temperature is 36.5 C (97.7 F), blood pressure is 160/90 mm Hg, and pulse is 108/min. Examination shows pain and mild stiffness with neck flexion. There are no cranial nerve deficits or muscle weakness.
A noncontrast head computed tomography scan reveals subarachnoid hemorrhage with no evidence of hydrocephalus. The patient is admitted to the intensive care unit. A few hours later, he complains of increasing headache and has 2 episodes of vomiting. Soon after, he develops cardiac arrest with pulseless electrical activity.
Which of the following interventions would have been the most effective in preventing this outcome?

Question

A 46-year-old man comes to the emergency department complaining of severe headache for the last 3 hours.  He took ibuprofen without much relief.  He suffers from tension headaches but says that this headache is nothing like those.  He feels nauseated and wants to move to a quiet, dark room.
His temperature is 36.5 C (97.7 F), blood pressure is 160/90 mm Hg, and pulse is 108/min.  Examination shows pain and mild stiffness with neck flexion.  There are no cranial nerve deficits or muscle weakness.
A noncontrast head computed tomography scan reveals subarachnoid hemorrhage with no evidence of hydrocephalus.  The patient is admitted to the intensive care unit.  A few hours later, he complains of increasing headache and has 2 episodes of vomiting.  Soon after, he develops cardiac arrest with pulseless electrical activity.
Which of the following interventions would have been the most effective in preventing this outcome?

Quizplus · Accepted Answer

11ec193a_970b_240b_853d_d7770d0925d5_MD0002_00 This patient has a subarachnoid hemorrhage (SAH) in the setting of severe headache and meningismus. SAH has a mortality rate of nearly 10% before patients reach the hospital and 25% within the first 24 hours of presentation. Rebleeding is the major cause of death within the first 24 hours, particularly within the first 6 hours. The initial step in managing suspected SAH is conventional angiogram as soon as possible with an endovascular approach (eg, coiling and/or stenting) to stabilize the aneurysm. (Choice A) Anti-fibrinolytic therapy (eg, tranexamic acid, epsilon aminocaproic acid) has not been shown to be effective in preventing rebleeding in patients with SAH. (Choices C and D) Hyperdynamic therapy (modest hemodilution, induced hypertension, hypervolemia) and nimodipine can effectively reduce the risk of vasospasm. However, this usually does not occur until after day 3. This patient's clinical course within the first 24 hours of SAH is most likely due to rebleeding. (Choice E) Ventricular drain placement is helpful in reducing intracranial pressure and increasing cerebral perfusion pressure. However, this patient's catastrophic event is likely due to rebleeding. Educational objective: In patients with subarachnoid hemorrhage, rebleeding is the major cause of death within the first 24 hours of presentation. Vasospasm usually does not occur until day 3. __________ References: How we do it: acute management of subarachnoid hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/23452572)

A 46-Year-Old Man Comes to the Emergency Department Complaining of Severe