Headache and subarachnoid haemorrhage

Manage now— do this, in order

• Airway first: GCS 8 or below, or inability to protect against vomit, requires intubation with the pressor response blunted (a BP surge can rupture the unsecured aneurysm): pre-oxygenate, fentanyl 1–2 microgram/kg IV about 3 minutes before laryngoscopy, propofol 1–2 mg/kg IV (ketamine 1–2 mg/kg IV if unstable), suxamethonium 1–1.5 mg/kg IV or rocuronium 1 mg/kg IV. Target SpO2 94–98%.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
• Position and fluid: nurse head-up at 30 degrees, head midline, quiet darkened room, absolute bed rest. Give 0.9% sodium chloride to maintain euvolaemia — never hypotonic fluid including 5% glucose, and never fluid-restrict a hyponatraemic SAH patient.
• Analgesia — uncontrolled pain drives hypertension and hypertension ruptures aneurysms: paracetamol 1 g IV or orally 6-hourly (max 4 g/24 h); morphine 2 mg IV every 5 minutes, typically 2–10 mg total, watching respiratory rate and GCS (paediatric: paracetamol 15 mg/kg/dose, morphine 0.1 mg/kg IV titrated). Never give NSAIDs or aspirin — they can convert a survivable bleed into a fatal one.Doctor / Nurse
• Antiemesis — every retch spikes intracranial and arterial pressure: ondansetron 4–8 mg IV over 2–5 minutes 8-hourly (paediatric 0.15 mg/kg IV, max 4 mg/dose) — preferred because it does not sedate; metoclopramide 10 mg IV 8-hourly is an adult alternative avoided under 20 years.Doctor / Nurse
• Nimodipine — the only drug shown to improve neurological outcome after aneurysmal SAH: 60 mg orally or by nasogastric tube every 4 hours for 21 days, started as soon as SAH is confirmed. Check BP before each dose: if systolic falls below 100 mmHg, give a fluid bolus and split to 30 mg every 2 hours rather than abandoning it. Never inject the oral preparation IV; nifedipine and amlodipine are not substitutes.
• Blood pressure before the aneurysm is secured: treat pain, vomiting, a full bladder and fear first; then keep systolic below approximately 160 mmHg without dropping mean arterial pressure more than about 25% in the first hour — labetalol 10 mg IV over 1–2 minutes repeated every 10 minutes (usual cumulative max 200 mg), or hydralazine 5 mg IV slowly repeated after 20 minutes. Never use sublingual nifedipine.Doctor / Nurse
• Reverse anticoagulation immediately: warfarin — vitamin K 5–10 mg by slow IV injection plus prothrombin complex concentrate (preferred) or fresh frozen plasma 15 mL/kg, target INR below 1.3; DOACs — idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors, PCC the usual alternative (FFP does not reliably reverse them). Stop antiplatelets but transfuse platelets only below 100 x 10^9/L.Doctor / NurseNot available at your setup — Blood & blood products, Coagulation (PT/INR).
• Seizures are treated as status epilepticus: lorazepam 4 mg IV (paediatric 0.1 mg/kg, max 4 mg) repeated once after 10 minutes, or diazepam 10 mg IV slowly; if persisting, levetiracetam 40–60 mg/kg IV (max 4.5 g) over 10 minutes or phenytoin 20 mg/kg IV at no more than 50 mg/minute with cardiac monitoring. No routine prophylaxis in a patient who has not fitted.Doctor / Nurse
• The supportive bundle and referral: lactulose 15 mL orally twice daily (straining raises transmural pressure across the aneurysm), mechanical thromboprophylaxis only until secured, treat fever, keep normoglycaemia, frequent serial neurological observations. Definitive treatment is coiling or clipping, ideally within 72 hours — Davidson's reduces immediate management to: resuscitate, nimodipine 60 mg, refer to neurosurgeons.