Volume 30, Number 1 BY KATHERINE A. ATASSI, RN, CNA, OCN, MSN MINDY L. HARRIS, RN, CNA, MSN Instructors * West Virginia University Institute of Technology * Montgomery, W.Va. Subarachnoid hemorrhage JAMES LOGAN, 47, is brought to your emergency department by ambulance. The paramedics tell you that en route to the hospital, Mr. Logan became unrespon- sive and experienced a generalized seizure. Now he’s extremely lethargic, but he responds to verbal stimuli and can move all extremities. What's the situation? Mrs. Logan says she and her husband were watching television when he complained of an exploding head- ache, then passed out. He has no history of trauma or syncope but does have a history of hypertension and cigarette smoking. ‘You examine Mr. Logan and find sluggish pupillary reaction to light and mild photophobia. His vital signs are: BP, 150/90; heart rate, 110; and respirations, 24. He has left-sided weakness, but other components of the physical examination are within normal limits. You establish another intravenous line, administer oxygen by nasal cannula at a rate of 2 liters/minute, and attach a pulse oximetry sensor to his finger. Obtain a 12-lead electrocardiogram and connect Mr. Logan to a cardiac monitor. Draw blood for chemistry profile, blood glucose level, complete blood cell count, and coagulation studies. Prepare Mr. Logan for a com- puted tomography (CT) scan of the head. What's your assessment? Mr. Logan’s signs and symptoms point to a neurologic problem. Results of the initial diagnostic studies are within normal limits, but the CT scan shows blood in the subarachnoid space, confirming subarachnoid hem- orthage. This type of bleeding is caused by the rupture of a blood vessel or an intracranial aneurysm, typically at the circle of Willis or major cranial artery branches and commonly after head trauma. Subarachnoid hemor- thage has a 40% mortality rate, and half the survivors are left with permanent neurologic deficits. Risk factors for subarachnoid hemorrhage include hypertension, smoking, alcohol or cocaine use, and pregnancy. Subarachnoid hemorrhages are more com- mon in women and African-Americans and in people ages 40 to 65. The hallmark symptom is a severe headache that comes on suddenly. hutp:/Avww:springnet.com What must you do immediately? Once the physician makes a preliminary dit subarachnoid hemorrhage, Prepare Mr. Logan fora cerebral ang have a lumbar puncture, unless they have increasing intracranial pressure (ICP). Treatment goals are to locate the site of bleeding, repair the damage (usually by clipping the aneurysm), and manage complications such as hydrocephalus, hyponatremia, seizures, and increased ICP. If the patient's respiratory pattern or airway is in jeopardy, he'll be intubated and mechanically ventilated. What should be done later? ’s angiogram shows an aneurysm in the cir- After surgery to clip the aneurysm, he’s admitted to the intensive care unit (ICU), where he'll be monitored for complications. His neurologic status will be assessed frequently. Mr. Logan will receive diazepam to alleviate anxi- ety and restlessness, codeine for pain control, and a calcium channel blocker such as nimodipine to prevent cerebral vasospasm. The physician also orders dexa- methasone sodium phosphate to reduce inflammation and docusate sodium, a stool softener, to prevent un- necessary straining that can increase ICP. Because of his previous seizure, Mr. Logan may also need anti- convuisant therapy. After several days in the ICU, Mr. Logan is trans- ferred to a rehabilitation facility for physical therapy to treat his left lower leg weakness and generalized muscle atrophy. Mursing2000, January 33