Plan – SAH patient, intubated

Template for plan of management (SAH patient, intubated)

Plan:

Neurological:
- Neurological checks q1h
- Seizure, fall, aspiration precautions
- Head of bed at 30 degrees at all times
- SBP goal 100-140 (aneurysm is not secured yet)
- Soft restraints while life saving devices in place (reviewed and necessary)
- Neurosurgery managing EVD
- CTH/CTA:
- No free water, mix everything in NS as this can worsen cerebral edema
- PT/OT/ST consults initiated
- TCD will be done daily
- Meds:
Nimodipine 60mg PO q4h
APAP 500 mg PO q6h PRN for pain or headache
Levetiracetam 750mg bid (for seizure prophylaxis)
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Respiratory:
- Aspiration precautions, head of bed above 30 degrees
- PRN O2
- Chest PT with vest q4hr
- Baseline CXR
- Suctioning q1-2 hours
- Meds:
Duonebs q4h
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Cardiology:
- Continuous cardiac telemetry
- SBP goal 100-140 (source of bleeding is unsecured yet)
- TTE for baseline EF (to guide IVF, cardene and pressor therapy if required)
- Meds:
Nicardipine drip (target SBP < 140)
Labetalol 10mg IV q4h prn
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Renal:
- Renal function normal
- Monitor daily BMP, Mg, Phos
- Foley with temperature probe for strict I&O monitoring in critical care setting
- Avoid hypotonic fluids as this can worsen cerebral edema
- Meds:
NS @ 75ml/h
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Gastrointestinal:
- NPO for now till speech evaluation
- Place Dobhoff tube for medication/nutrition; Abdominal X-ray to confirm placement ordered
- Start tube feeding with Peptamen 1.5 @ 10cc/hr and titrate to goal 50cc/hr as tolerated
- Hold TF for residuals > 300
- Last BM: unknown
- Meds:
1. Docusate 100 mg PO TID
2. Pantoprazole 40mg tab daily
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Endocrinology:
- FSBS q6hr while NPO/TF
- Check HgbA1c, TSH
- Meds:
Insulin SS q6h while NPO then ACHS
Hypoglycemia protocol
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Hematology:
- Monitor CBC daily
- SCDs for prophylaxis; no heparins given acute subarachnoid bleed
- Meds:
None
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Infectious Disease:
- Current access: PIVs (placed), will place PICC line
- Keep normothermic, aggressive fever control as it worsens neurological outcomes
- Meds:
​ 1. APAP 500mg q6hr PRN for fever >38.3

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Prophylaxis:
DVT: SCDs, no anticoagulation in the setting of recent subarachnoid bleed
GI: famotidine, docusate
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Consults:
Neurointervention
Neurosurgery
Physical therapy
Occupational therapy
Speech therapy
Nutrition
Case Management
Social Work
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Discharge Planning:
Patient requires ICU level of care for monitoring of potential complications of SAH (rebleeding, vasospasm, hydrocephalus)
Patient was discussed with the neurocritical care attending who agrees with current plan of management.

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Explanation:

-> Nurses usually do MEND exam .
-> Seizure precauti