Haemorrhage Command Bench: Pressure, Reversal and the Vasospasm Calendar
In a bleed the vessel is already open, so every rule from ischaemic stroke reverses: pressure now drives haematoma expansion instead of protecting a penumbra. Drive the systolic to target, match the anticoagulant to the right reversal agent, then walk the twenty-one day subarachnoid calendar and watch the three killers arrive in order — rebleeding, hydrocephalus, then vasospasm.
Mr Okonkwo, 71. Sudden left hemiplegia worsening over 40 minutes, severe headache, vomiting, drowsy. CT shows a right basal ganglia haematoma. Arrival blood pressure 196/104 mmHg, platelets 210,000/mm³.
Systolic pressure you will drive him to
Target systolic196 mmHg
How you will get there
What is he anticoagulated with?
Reversal you will ask for
Ms Reyes, 52. Thunderclap headache maximal within seconds, brief loss of consciousness, vomiting, photophobia, nuchal rigidity. CT confirms aneurysmal subarachnoid haemorrhage. Move the dial to walk her admission day by day.
Hospital day
Day since the bleedDay 0
Has the aneurysm been secured by coiling or clipping?
Blood pressure before the 1000 nimodipine dose
Systolic148 mmHg
Nimodipine is 60 mg orally or by nasogastric tube every 4 hours for 21 days after aneurysmal subarachnoid haemorrhage — and it is never given intravenously.
Pick the patient
Your diagnosis
Your treatment
Both patients have a serum sodium of 128 mEq/L on day 4 after subarachnoid haemorrhage. Hyponatraemia occurs in up to a third of these patients, and the two causes need opposite treatments.