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A practical guide to the management of medical emergencies - part 6

Có máu trong không gian dưới nhện • thủng trong não tụ máu vùng thắt lưng nếu CT là bình thường • Lớn lên áp lực mở • Thống nhất máu nhuộm dịch não tủy sống (CSF) • Xanthochromia bề (luôn luôn tìm thấy từ 12 h đến 2 tuần sau khi bị chảy máu, máy ly tâm dịch não tủy và kiểm tra các bề quang phổ nếu có | 324 SPECIFIC PROBLEMS NEUROLOGICAL TABLE 49.4 Urgent investigation in suspected subarachnoid hemorrhage CT of the brain Blood in subarachnoid spaces May show intracerebral hematoma Lumbar puncture if CT is normal Raised opening pressure Uniformly blood-stained cerebral spinal fluid CSF Xanthochromia of the supernatant always found from 12 h to 2 weeks after the bleed centrifuge the CSF and examine the supernatant by spectrophotometry if available if not compare against a white background with a control tube filled with water Other investigations Full blood count Coagulation screen Blood glucose Sodium potassium and creatinine ECG Chest X-ray ALERT If the CSF findings are equivocal in a patient with suspected subarachnoid hemorrhage cerebral angiography may be indicated to exclude an intracranial aneurysm seek advice from a neurologist or neurosurgeon. CHAPTER 49 325 TABLE 49.5 Nimodipine after subarachnoid hemorrhage To prevent ischemic neurological deficits give nimodipine 60 mg 4-hourly by mouth or nasogastric tube for 21 days To treat ischemic neurological deficits give IV via a central line 1 mg h initially increased after 2 h to 2 mg h if no significant fall in blood pressure. Continue for at least 5 days max. 14 days Other calcium-channel blockers and beta-blockers should not be given while the patient is receiving nimodipine TABLE 49.6 Monitoring and supportive care after subarachnoid hemorrhage Admit the patient to ITU HDU Monitor conscious level Glasgow Coma Scale score see Table 46.2 pupils respiratory rate arterial oxygen saturation heart rate blood pressure temperature fluid balance and blood glucose initially 2-4-hourly Give analgesia as required e.g. paracetamol 1 g 6-hourly and or codeine 30-60mg 4-hourly PO . Add a benzodiazepine if needed for anxiety. Start a stool softener to prevent constipation Ensure an adequate fluid intake to prevent hypovolemia initially 3L normal saline IV daily. Check electrolytes and creatinine at least every other day If