EM Cases · Subarachnoid haemorrhage
Subarachnoid haemorrhage — the deteriorating resus station
An ACEM Fellowship resus station: thunderclap recognition, CT timing, nimodipine and blood pressure, neurovascular activation, and the patient whose consciousness falls.
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Prompt
A middle-aged patient with thunderclap headache whose conscious state falls after a confirmed SAH.
Station brief
Format. Clinical-management (resus) station. You are the ED consultant.[1]
Scenario. A 55-year-old with a sudden severe headache 2 hours ago; CT shows diffuse subarachnoid blood. BP 196/104. Forty minutes later her GCS falls from 15 to 10.[2]
Reveal the expected management (assessor key)ShowHide
- Confirm the diagnosis. CT within 6 hours identified all 121 SAH in Perry's cohort; SHED reported 97% sensitivity.[2][3]
- Oral nimodipine (60 mg four-hourly reduced infarction and poor outcome).[5]
- Blood pressure. Lower very high BP slowly, without undershoot, with short-acting drugs (expert opinion); MAP below 100 mmHg was associated with less rebleeding and below 60 mmHg with more DCI.[1][6]
- Falling GCS. Repeat CT for rebleeding or hydrocephalus; drainage is recommended for hydrocephalus with reduced consciousness.[1]
- No tranexamic acid; urgent neurovascular referral — aneurysm treatment ideally within 24 h; coiling preferred when both options suit (ISAT).[1][4]
References6ShowHide
- [1]Vergouwen MDI, Ramos-Pachon A, Terecoasa EO, et al. European Stroke Organisation (ESO), European Association of Neurosurgical Societies (EANS) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on aneurysmal subarachnoid haemorrhage. European stroke journal, 2026.PMID 42095754
- [2]Perry JJ, Stiell IG, Sivilotti ML, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ (Clinical research ed.), 2011.PMID 21768192
- [3]Trainee Emergency Research Network (TERN) Subarachnoid haemorrhage in the emergency department (SHED): a prospective, observational, multicentre cohort study. Emergency medicine journal : EMJ, 2024.PMID 39266054
- [4]Molyneux A, Kerr R, Stratton I, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet (London, England), 2002.PMID 12414200
- [5]Pickard JD, Murray GD, Illingworth R, et al. Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial. BMJ (Clinical research ed.), 1989.PMID 2496789
- [6]Gathier CS, Zijlstra IAJ, Rinkel GJE, et al. Blood pressure and the risk of rebleeding and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Journal of critical care, 2022.PMID 36208555