Prehospital Management of Subarachnoid Hemorrhage (SAH)

Initial Assessment and Transport

The American Heart Association recommends that emergency medical services (EMS) personnel maintain a high index of suspicion for SAH in patients presenting with severe headache, altered level of consciousness, or vomiting, even without focal neurological deficits 1, 3
The American College of Cardiology suggests that a rapid assessment and transport model should be employed, similar to that used for acute ischemic stroke, to minimize time to definitive care 1, 2
Hospitals with low volume of SAH cases (<10 per year) should consider early transfer to high-volume centers (>35 cases per year) with experienced cerebrovascular surgeons and multidisciplinary neurointensive care services, as recommended by the American Stroke Association 4

The American Heart Association recommends ensuring and maintaining adequate airway, breathing, and circulation, with specific attention given to preoxygenation, pharmacological blunting of reflex dysrhythmia, and avoidance of unnecessary blood pressure fluctuations during intubation 1, 2
The American College of Emergency Physicians suggests that following intubation, placement of a nasogastric or orogastric tube is recommended to reduce aspiration risk, and appropriate oxygenation without hyperventilation should be maintained and assessed with oximetry 1, 2

The American Stroke Association recommends that blood pressure should be controlled with a titratable agent to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure, with a goal of avoiding systolic blood pressure >160 mmHg 4, 5, 6

The American Academy of Neurology recommends that emergency care providers evaluate SAH patients using an accepted grading scale, such as the Hunt and Hess Scale, Fisher Scale, Glasgow Coma Scale, or World Federation of Neurological Surgeons Scale, and record it 1, 2
The degree of neurological impairment using these scales is useful for prognosis and triage, as suggested by the American Stroke Association 1, 2

The American Heart Association warns that SAH is frequently misdiagnosed, and maintaining high suspicion in patients with acute onset of severe headache is crucial, with a strength of evidence level of IIa 3, 4
The American College of Emergency Physicians advises against hyperventilation in intubated patients, as it may worsen cerebral ischemia, with a strength of evidence level of III 1, 2
The International Stroke Society recommends avoiding excessive fluid administration that could worsen cerebral edema, but maintaining euvolemia, with a strength of evidence level of IIb 7

The American Heart Association suggests that EMS personnel should receive continuing education regarding the importance of rapid neurological assessment when altered level of consciousness is encountered, with a focus on recognition of SAH symptoms and the time-sensitive nature of this condition 1, 2