Trust Guideline for Urgent Brain Imaging and Management of Suspected Subarachnoid Haemorrhage

Transcription

1 A Clinical Guideline Fr Use in: Accident & Emergency, Acute Medical Unit, Medical wards By: Medical staff Fr: Adult patients presenting with suspected subarachnid haemrrhage Divisin respnsible fr dcument: Medical Key wrds: Subarachnid Haemrrhage Gdwin Mamutse and Linda Damian, Names and jb titles f dcument Cnsultant Neurlgists and Janak Saada, authr s: Cnsultant Radilgist Name f dcument authr s Line Manager: Dr Jeff Cchius Jb title f authr s Line Manager: Clinical Directr, Neurlgy Supprted by: Dr Javier Gmez, Cnsultant in Clinical Bichemistry Clinical Guidelines Assessment Panel Assessed and apprved by the: (CGAP) If apprved by cmmittee r Gvernance Lead Chair s Actin; tick here Date f apprval: 03/03/2016 Ratified by r reprted as apprved t (if applicable): T be reviewed befre: This dcument remains current after this date but will be under review T be reviewed by: Clinical Standards Grup and Effectiveness Sub-Bard 03/03/2019 Dr G Mamutse Reference and / r Trust Dcs ID N: CA5070 Id N: 8886 Versin N: 2 Descriptin f changes: Cmpliance links: (is there any NICE related t guidance) If Yes - des the strategy/plicy deviate frm the recmmendatins f NICE? If s why? N clinical changes Nne This guideline has been apprved by the Trust's Clinical Guidelines Assessment Panel as an aid t the diagnsis and management f relevant patients and clinical circumstances. Nt every patient r situatin fits neatly int a standard guideline scenari and the guideline must be interpreted and applied in practice in the light f prevailing clinical circumstances, the diagnstic and treatment ptins available and the prfessinal judgement, knwledge and expertise f relevant clinicians. It is advised that the ratinale fr any departure frm relevant guidance shuld be dcumented in the patient's case ntes. The Trust's guidelines are made publicly available as part f the cllective endeavur t cntinuusly imprve the quality f healthcare thrugh sharing medical experience and knwledge. The Trust accepts n respnsibility fr any misunderstanding r misapplicatin f this dcument. N/A Available via Trust Dcs Versin: 2 Trust Dcs ID: 8886 Page 1 f 6

2 Quick reference guideline/s Objective/s Available via Trust Dcs Versin: 2 Trust Dcs ID: 8886 Page 2 f 6

3 T utline the investigatins (imaging and CSF analysis) and initial management f suspected subarachnid haemrrhage (SAH) at the Nrflk and Nrwich University Hspital (NNUH) Ratinale Subarachnid haemrrhage (SAH) frm a ruptured aneurysm carries a significant risk f disability r death (arund 30% mrtality) and the diagnsis is easily missed if apprpriate investigatin des nt take place. Since there is a 20-40% risk f early re bleed, which carries a 75% chance f death r disability, prmpt diagnsis and treatment is required. CT brain scan will be perfrmed urgently, with an aspiratinal target f within 1 hur f request, nce SAH is suspected. CT brain scan, withut cntrast, is highly sensitive fr the detectin f subarachnid bld but the sensitivity declines ver time, frm % in the first 24 hurs t arund 50% after 5-7 days. Where CT brain imaging des nt demnstrate subarachnid bld, CSF bilirubin spectrphtmetry is required as cnfirmatry evidence f a subarachnid haemrrhage. As the frmatin f bilirubin in CSF may be delayed by 12 hurs frm symptm nset, lumbar puncture (LP) shuld be perfrmed at least 12 hurs after symptm nset. CSF bilirubin spectrphtmetry may remain psitive fr up t 2 weeks after headache nset. If the CT brain scan and CSF examinatin within 14 days f initial symptms are bth negative, SAH has been ruled ut. Beynd this time perid bld prducts may have been reabsrbed, s cnsideratin shuld be given t perfrming CT angigraphy (CTA) f intracranial vessels t lk fr an aneurysm, usually in cnsultatin with the reginal vascular neursurgery service at Addenbrke s Hspital. Brad recmmendatins Subarachnid haemrrhage (SAH) presents with sudden nset severe headache. It is estimated that the diagnsis is missed in 20-50% f cases at first presentatin and the incidence f apprximately 7 per persn years means that a GP will see abut ne patient with SAH every 7 years. In rder nt t miss the diagnsis, it must be suspected much mre ften than the diagnsis is actually cnfirmed. Therefre, all first r wrst headaches arising within a few minutes require investigatin. The algrithm abve utlines the expected investigatin f patients presenting t the NNUH with symptms suggestive f SAH. Further angigraphic investigatin f acute SAH t detect an aneurysm takes place at the reginal neursurgery centre in Cambridge, where the aneurysm can be treated by ciling r clipping. This requires transfer f the (ften critically ill) patient fllwing cnfirmatin f the diagnsis, adding delay t the management f patients with SAH presenting t the NNUH. Given the significant risk f re-bleeding, which may be fatal r disabling, and the imprved utcme with early definitive treatment f an aneurysm, prmpt transfer must take Available via Trust Dcs Versin: 2 Trust Dcs ID: 8886 Page 3 f 6

4 place. This dcument intends t aid decisin making s that delay can be kept t a minimum. The fllwing sectins summarise initial investigatins and management f patients with suspected r cnfirmed SAH. Investigatins Urgent CT brain scan, within an aspiratinal target f 1 hr frm request (ensure ICE request is cmpleted befre cntacting duty radilgist with request fr scan) If CT brain scan is nrmal, SAH shuld be excluded by perfrming a lumbar puncture (LP) between 12 hrs and 14 days after symptm nset, measuring pening pressure and submitting CSF fr: Xanthchrmia (bilirubin spectrphtmetry) submit the least bld stained specimen, usually the last cllected, cvered in tin-fil t prevent bilirubin breakdwn submit paired serum bld sample fr bilirubin measurement recrd date and time f headache nset and the date and time f the LP n the request card clearly state the date and time f any LP that has been perfrmed recently- the result may be falsely cnsistent with SAH if the LP was perfrmed within the previus 14 days avid using the pneumatic tube system t transprt the sample MC&S, glucse (with paired bld glucse sample) and prtein When lumbar puncture perfrmed, immediately send sample t Clinical Bichemistry, ensuring technlgist is infrmed by telephne, fr centrifugatin befre bilirubin spectrphtmetry. This is especially imprtant if tap was traumatic. Immediate management f cnfirmed subarachnid haemrrhage If cnsciusness impaired, check and maintain airway 1-2 hurly BP, Pulse, Respiratin, Oxygen saturatins, Temperature and neurlgical bservatins Bed rest with maximum 30 degree elevatin Patient can get up fr cmmde use nly Apply TED stckings Keep nil by muth Analgesia: Paracetaml 1g QDS ± Cdeine Phsphate 30-60mg QDS Available via Trust Dcs Versin: 2 Trust Dcs ID: 8886 Page 4 f 6

5 Nimdipine 60mgs 4 hurly, rally r via nasgastric tube (tablets may be crushed) If n cntraindicatin, give sdium chlride 0.9%, at least 3 L every 24 hr D nt use Gelfusine r Dextrse r Dextrse Saline Cntrl hypertensin by maintaining systlic BP between 120 and 150mmHg Cntact n call Neursurgical Registrar at Addenbrke s Hspital t arrange urgent transfer fr CTA r digital subtractin angigraphy t rule ut r treat aneurysm (recmmendatin within hurs frm ictus) An anti-emetic shuld be given prir t jurney Clinical audit standards This guideline will be audited peridically t ensure that the standards laid ut are being met. The audit results will be sent t the Clinical Directrs f Radilgy and Neurlgy wh will review the results and make recmmendatins fr further actin. Summary f develpment and cnsultatin prcess undertaken befre registratin and disseminatin Recmmendatins frm an audit n the management f subarachnid haemrrhage included a requirement fr a guideline n subarachnid haemrrhage. The first editin f this guideline was circulated fr cmment t cnsultants in A&E, Critical Care, Radilgy and Neurlgy. Cmment regarding CSF analysis has been sught frm Dr Javier Gmez, Cnsultant Clinical in Clinical Bichemistry. This versin has been endrsed by the Clinical Guidelines Assessment Panel. Distributin list/ disseminatin methd This guideline shuld be disseminated t Gvernance Leads and Clinical Directrs within the NNUH. Available via Trust Dcs Versin: 2 Trust Dcs ID: 8886 Page 5 f 6

6 References 1: Brwn SC, Brew S, Madigan J. Investigating suspected subarachnid haemrrhage in adults. BMJ May 6;342:d2644. di: /bmj.d2644. PubMed PMID: : Cruickshank A, Auld P, Beetham R, et al. Revised natinal guidelines fr analysis f cerebrspinal fluid fr bilirubin in suspected subarachnid haemrrhage. Ann Clin Bichem 2008; 45: : Davenprt R. Acute headache in the Emergency Department. Jurnal f Neurlgy Neursurgery and Psychiatry 2002; 72:ii33-ii37 4: Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnid hemrrhage. N Engl J Med Jan 26;354(4): Review. PubMed PMID: : van Gijn J, Kerr RS, Rinkel GJ. Subarachnid haemrrhage. Lancet Jan 27;369(9558): Review. PubMed PMID: Available via Trust Dcs Versin: 2 Trust Dcs ID: 8886 Page 6 f 6