The Subarachnoid Haemorrhage Survivor

This is a favourite. The general issues to consider are:

  • Severity
  • Neurological deficits
  • Vasospasm (and its assessment)
  • Cardiovascular complications of the SAH, and of its treatment
  • Endocrine complications (such as DI, SIADH and cerebral salt wasting)

Previous hot cases with this sort of theme to them can be found below.

Examination of the Patient with Subarchnoid Haemorrhage

The standard introduction

  • The examiner will give you a history.

The prelude to the dance

  • Wash hands.
  • Gown and glove.
  • Ask, if relevant:
    • "Can I turn on all the lights?"
    • "Are there any movement restrictions? Can I sit them up, or roll them on their side?"
    • "Is there a language barrier?"
  • Introduce yourself: “Hi Mr or Mrs Bloggs, I’m Dr So-and-so. I’m going to examine you.”

The Monitors

  • Rhythm
  • Rate
  • Morphology
  • MAP and abnormal morphology of the arterial waveform
  • CVP and abnormal morphology of the CVP waveform
  • ICP
  • Ancillary waveforms eg. the PA catheter waveform
  • Oxygen saturation measurement, and the quality of the waveform
  • End-tidal CO2 waveform and level

The Ventilator

One can ask the examiners the following questions:

  • How are we oxygenating this patient?
  • How are we ventilating this patient?
 

One should ask about the following parameters:

  • FIO2
  • PEEP
  • Peak pressure
  • Plateau pressure
  • Tidal volume and minute volume

One should ask to look at the pressure-volume loops.

The presence of neurogenic pulmonary oedema should make itself apparent in the ventilator settings.

Urine catheter

  • Unusual colour
  • Anuria
  • Polyuria due to DI or cerebral salt wasting

Drains (surgical, intercostal, etc)

There may be surgical drains (what is in them? How much of it?). Asking how much has been coming out may be relevant in a hot case which focuses on the diagnosis of a shock state.

The pleural catheters are also interesting. One should make a mental note of whether the ICCs are on free drainage or on suction. The content of these drains could be informative, especially if one notices blood or chyle.

Infusions

This stage is critically important. The drug and fluid infusions which are currently in progress give a clue as to what problem is currently being addressed. Nimodipine and noradrenaline are the usual tenants of the infusion stack.

EVD

One should observe the following features of an EVD:

  • Set height
  • Whether it is open or closed
  • The CSF colour - eg. is it full of blood?

Weird machinery

A transcranial doppler machine may be present, suggesting that there has been a recent interest in the possibility of vasospasm.


The physical examination

Expose and observe

Ideally, one should get the patient sitting up to 30-45°. This may not be possible. However, one should still ask for it.

Ideally, the patient should be exposed from the waist up. The candidate can then stand back and look for anything externally obvious:

  • Skin colour, eg. jaundice or the discolouration of chronic renal failure
  • Muscle wasting, obesity
  • The evidence of trauma, wound dressings, etc
  • The pattern of breathing (eg. whether there is a characteristic chest flail)

GCS

Performing the GCS should be the first step, unless you notice that a neuromuscular junction blocker is among the infusions. The level of consciousness then determines how you go about examining the rest of the patient.

A traditionalist, who is examining Mr Bloggs, would approach the GCS in the following manner:

  • Grab hold of both of the patient's hands.
  • "Mr Bloggs!" One pauses to observe for eye opening.
  • "Can you squeeze my hands?"
  • If hand squeezing and eye opening is not observed, one administers a painful nail bed stimulus to both hands, to observe the response to pain.

It would be interesting (if fruitless) to ask what the GCS on presentation was, and whether there were any focal deficits.

Hands, nail signs, pulse and the arterial line.

One has just performed a GCS assessment; one is still holding the hands.

Now, time to look at them more closely.

First, one should spent a second assessing whether they are warm or cold.

Then, one can focus on the nails. Nail signs are numerous and deserve their own page. The examination of the SAH patient should not require a prolonged scrutiny of the nails. Rather, evidence of smoking should suffice. Splinter haemorrhages might lead one to suspect mycotic aneurysm due to IE, or a vasculitis.

One should note the presence of any sort of characteristic deformities, eg. assymetrical wasting of the small muscles, or the joint changes of rheumatoid arthritis. Widespread changes of vasculitis may be apparent; the hands and forearms may be covered in the characteristic bruising of chronic anticoagulation.

Next comes the pulse. While one still has both of the patient's hands, one ought to try to compare the radial pulses. It would be worthwhile to look up at the arterial line trace at this stage; abnormalities such as the widened pulse pressure of aortic regurgitation may not have been noticed until this stage.

Arms

Tone of the upper limbs

Move up from the hands. While you are still holding the hands, you can perform a sort of gross examination of tone by pronating and supinating the wrists, and by flexing and extending the elbows.

Asterixis

In the conscious patient, it may be possible to assess asterixis by asking the patient to hold both their arms up with the wrists dorsiflexed.

Cubital fossa

Examine the cubital fossa for

  • Peripheral lines
  • Evidence of multiple venepunctures
  • Lymph nodes
  • Brachial pulse
  • The presence of an obvious AV fistula

One should then palpate the axillary lymph nodes.

The Neck

  • Inspect any central lines
  • Look again at the CVP

Palpate the neck:

  • Trachea: is it midline? Is there a new tracheostomy there?
  • Thyroid gland
  • Cervical lymph nodes
  • Carotid pulse - one side at a time!
  • Submandibular lymph nodes
  • Pre- and post-auricular lymph nodes

Pupils and the higher cranial nerves

The exact sort of examination one is able to perform is dependent entirely on the level of consciousness. A fully conscious extubated patient can perform the entire spectrum of cranial nerve tests; a deeply unconscious patient may have no motor response to pain, and one will be limited to testing the reflexes only; a paralysed patient won't even have those.

Thus, this section can be divided into three broad groups:

The paralysed patient The unconscious patient The awake patient

A sophisticated and detailed cranial nerve examination is desirable, but impossible within the timeframe permitted by the hot case. The candidate should attempt to discern some bare minimum of cranial nerve signs.

Visual acuity

A Snellen chart is ideal, but probably will not be available.

The extubated patient should be able to read the time on the clock in the room.

One performs this test with each eye individually.

This tests CN II.

Light reflex

Ask the examiners to dim the room lights.

Open both eyes. Each eye is exposed to light. The opposite pupil should constrict consensually.

This tests CN II (afferent) and CN III (efferent).

A CN III lesion may point to the PCOM as the site of the aneurysm

Corneal reflex

The cornea (not the sclera) is touched lightly with a moistened corner of a piece of gauze.

A normal reflex is to blink.

This tests CN V (afferent) and CN VII (efferent)

Eye movements

The conscious patient will be able to follow the tip of the candidate's finger.

The pattern of movements should be tracing the six cardinal points: superior left, inferior left, superior center, inferior center, superior right, inferior right.

This tests CNs III, IV and VI.

Facial pain sensation

Typically, this is performed by putting some pressure on the superior orbital notch.

The patient should either open their eyes or localise.

This tests CN V.

Facial movements

The conscious patient will be able to perform a series of grimaces to assess the bilateral motor control of facial muscles:

  • Raise eyebrows to wrinkle forehead
  • Squint eyes to assess periorbital muscles
  • Bare teeth to assess nasolabial muscles
  • Blow out cheeks

Oculocephalic reflex

In the comatose patient, as the head is moved from left to right, the eyes should move in the opposite direction. A fixed unchanging gaze is a negative test; the reflex is not working.

This tests CNs III, IV, VI, and most importantly VIII.

Cold caloric reflex

Cold water is funneled into the patient's ear. A positive reflex consists of the eyes turning towards the chilled ear. This is a more potent stimulus for CN VIII than the oculocephalic reflex.

Airway and the lower cranial nerves

Now that one has finished with the upper cranial nerves, one can move on to the mouth, airway, and swallowing apparatus.

Gag reflex

The Yankeur sucker is used to probe the posterior pharynx, on both sides. A gag reaction should result from this.

This collectively tests CN X and IX.

Cough reflex

While on the subject of CN X, one may test the cough reflex by suctioning the trachea.

This tests CN X.

This is also a convenient time to ask about the volume and character of the secretions.

Tongue movements

The conscious patient is asked to protrude their tongue, and move it from side to side.

This tests CN XII.

Uvula deviation

The uvula deviates away from the lesion.

This tests CN X and IX.

Shoulder shrug

The conscious patient is asked to shrug their shoulders against resistance.

This tests CN XI.

During the cranial nerve examination, one will inevitably end up tripping over the endotracheal tube.

Chest palpation, percussion and auscultation

Palpation:

One puts both their hands on the chest to assess the symmetry of chest expansion.

Percussion:

One might wish to percuss the chest.

Changes in percussion resonance may be worth commenting on.

Auscultation:

One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible. The money is in the bases.

Palpation and auscultation of the praecordium

Palpation:

The clever candidate will make a big show of palpating both the apex and the right sternal edge.

Auscultation:

One should auscultate in the following sequence:

  • Apex
  • Left sternal edge, lower
  • Left sternal edge, upper
  • Right sternal edge, lower
  • Left sternal edge, upper
  • Both carotids

The various clicks and murmurs one encounters are discussed elsewhere.

Abdominal palpation, percussion and auscultation

For this, one should ask to lay the patient flat.

Abdominal observation

  • Take a moment to behold the abdomen. One may ask the examiners to look under any surgical dressings; one is likely to be denied this part of the examination (they will tell you the wound looks clean and dry).

Abdominal palpation

  • All quadrants should be palpated.
  • Then, feel for the liver edge; observe respiratory excursion
  • Then, feel for the spleen.
  • Then, try to ballot the kidneys. Enquire about renal tenderness.
  • Large kidneys may suggest polycystic kidney disease as an associated pathology.

Abdominal percussion

  • This can double as a test for peritonism.
  • If there is some suspicion of ascites, one may ask to roll the patient, so shifting dullness can be better appreciated. The examiners may not permit this test.

Abdominal auscultation

  • One should spend a good length of time on this, if one suspects bowel obstruction or ileus.

Examination of the pelvis and groins

The pelvic content would have been palpated during the abdominal examination.

The more important part of this examination is the groin.

At this stage, the patient should be re-draped - cover them from the waist up, and uncover their legs.

Observation and palpation of the pelvis:

  • There may be a rash of thrush, or a groin haematoma, or an external fixation device.
  • The posterior pelvis and sacrum should ideally be palpated for pitting oedema.

Examination of the lines

  • One should take notice of anything going into or coming out of the femoral vessels.
  • There may be a vascath, a PiCCO catheter or some sort of angiography sheath. These are important clues. The angio catheter may suggest a recent intra-arterial injection of vasodilators, or an attempt at coiling.

Examination of the genitals and rectum

  • A complete examination would call for the palpation of the testes, and a comment on their size. However, this may not be practical.
  • One should take note of any sort of waste management devices, eg. rectal tube, SPC or IDC.
  • One should definitely ask about performing a PR.
  • If one is forbidden from performing the PR, one should ask about the following features:
    • Anal sphincter tone
    • Size and quality of the prostate
    • Presence of melaena or hard stool

Once one is finished with the pelvis, one should cover it again, so that only the legs are sticking out.

Examination of the lower limbs

One should ask to remove TEDs and compression stockings.

  • One should observe whether the lower limbs are mottled, and whether they are of the same size (assymetrical swelling leads one to suspect lymphoedema or DVT)
  • One should palpate the larger muscles. Muscle wasting - especially of the quads- is an important feature of malnutrition. Additionally, one gets to appreciate the temperature difference between the limbs, which could be important in the assessment of peripheral vascular disease, and the complications of angiography.
  • Pitting oedema should be palpated.

Leg muscle tone

The best way to test muscle tone is by holding the knee. Roll the knee gently to distract the patient; then try to lift it off the bed. In the presence of increased tone, the leg will remain straight and the whole thing will lift up; with normal or decreased tone, only the knee will bend

Calf tenderness

In the conscious patient, one might be able to assess whether a gentle calf squeeze produces the characteristic pain which suggests a DVT may be present.

This brings one to the feet, and to the beginning of the neurological examination.

Feet and the Babinsky reflex

The feet would have already been palpated to assess their temperature, and to look for pitting oedema.

Observation of the feet

One should look specifically for changes suggestive of chronic diabetic foot disease, or chronically poor vascular supply.

Palpation of the feet

This should consist of palpating the dorsalis pedis and posterior tibial pulse.

Babinsky reflex

One should test the Babinsky bilaterally.

Clonus

One should attempt to assess clonus in both feet.

Power in the lower limbs

Now is the time to properly start the neurological examination of this patient.

Power of the muscle groups may be tested in the following sequence:

  • Ankle dorsi and plantarflexion
  • Knee flexion and extension
  • Hip flexion, extension, adduction and abduction.

Lower limb weakness may suggest the ACOM as a site of the aneurysm.

Power in the upper limbs

The patient has spent most of this time flat and supine. Time to sit them back up again.

Power of the upper muscle groups may be tested in the following sequence:

  • Hand grip
  • Wrist dorsiflexion/palmarflexion
  • Elbow flexion/extension
  • Shoulder adduction / abduction

Reflex testing

Now that one is back to the upper limb, one may as well start their reflex tests there.

The reflexes may be tested in the following order:

  • Brachioradialis
  • Biceps
  • Triceps
  • Knee jerk
  • Ankle jerk

Sensory testing

After testing the ankle jerk reflex, one is again back to the feet.

At this stage, with a conscious patient, one may wish to test light touch sensation.

The following order (with corresponding dermatomes) is suggested:

  • Sole of the foot (S1)
  • Lateral lower leg (L5)
  • Medial lower leg (L4)
  • Medial knee (L3)
  • Anterior upper quads (L2)
  • Umbilicus (T10)
  • Nipple level (T5)
  • Medial forearm (T1)
  • Pinky finger (C8)
  • Middle finger (C7)
  • Thumb (C6)
  • Lateral forearm (C5)
  • Posterior shoulder (C4)

The cerebellar examination of the critically ill patient

Now, usually, the cerebellum requires all sorts of dynamic manoeuvres- one should assess the gait, balance, speech, and so forth. The intubated ICU patient does not permit the majority of these. They are so entangled in tubes they may not be able to perform dysdiadochokinesis.

The following is a list of cerebellar tests one may be able to perform with an intubated ICU patient.

Many of these findings would have been discovered during earlier stages of the examination.

Nystagmus

This would have become apparent during the testing of the eye movements.

Resting tremor

This would have become apparent during the test for nystagmus

The finger-nose test

This is an assessment of coordination. The patient is asked to alternate between touching their nose and touching the finger of the candidate, who keeps changing its position.

The heel-shin test

The patient is asked to run the heel of one foot along the shin of the opposite leg.

The measured observations

Ask to see the obs chart. If it is not allowed, ask for the following:

  • Trends of blood pressure and heart rate
  • Temperature
  • Drain output
  • Urine output - this may be very important; one does not wish to miss a case of DI.

One may also wish do demonstrate an interest in the trends of any sort of advanced haemodynamic monitoring, eg. cardiac index as measured by PAC or PiCCO

The laboratory investigations

One needs to show an interest in the following labs:

  • ABG
  • Routine bloods
  • Urinalysis
  • Culture results
  • Case-specific bloods, eg. CK, troponin, LFTs, pancreatic enzymes, inflammatory markers...

Imaging and other investigations

One should always ask for the following:

  • ECG
  • CXR
  • CSF analysis
  • CT, CTA, MRI or DSA images
  • TTE
  • Urinary electrolytes - particularly, sodium

 

Case presentation and discussion: when you have a good idea of what is going on

"Mr Bloggs is suffering from [insert grade of SAH here]."

"This SAH is complicated by [vasospasm, aspiration pneumonia, neurogenic pulmonary oedema, Takotsubo cardiomyopathy]"

"I have come to this conclusion on the basis of the following findings: [insert clinical findings here]"

"I would like to confirm my diagnosis with the following investigations: [insert appropriate investigations]"

"The current management issues are as follows: [a brief list of management priorities]"

"I would approach the management of these issues in the following manner: [list of management strategies; it helps to organise this into an A,B,C,D,E approach if one has a complex multisystem problem to manage]"

Case presentation and discussion: when you don't have a clue

"Mr Bloggs is suffering from [insert grade of SAH here]."

"This SAH may be complicated by [vasospasm, aspiration pneumonia, neurogenic pulmonary oedema, Takotsubo cardiomyopathy]. However, on my examination I have not identified any features which might be consistent with these complications".

"I have identified the following clinical findings: [insert list of findings]." "The possible aetiologies responsible for these findings could include [list of differentials]"

"In order to discriminate between these differentials, I would like to perform the following investigations: [list of investigations]"

"Furthermore, I would like to investigate for the complications of SAH by the following methods [DSA, CTA, CTB, CSF analysis]"

Number of previous hot cases in this topic: 19

2015, Paper 2

Unspecified hospital in Adelaide

60-year-old male, ICU day 9, presented following a seizure at work secondary to a sub arachnoid haemorrhage, with an initial GCS of 6. The aneurysm was clipped on day 1 and he subsequently failed extubation. Clinical findings included hypertension, the presence of an EVD wound scar, GCS E1 M2-3 VT, hypotonia, no response to facial pain and upgoing plantars bilaterally.

Candidates were directed to assess and explain his neurological status.

Discussion points included causes for deterioration after sub-arachnoid haemorrhage, investigation and management of vasospasm, and the causes of fever.

2015, Paper 1

Unspecified hospital in Melbourne

56 - year - old female, day 2 in ICU, admitted following a sub-arachnoid haemorrhage (WFNS grade 2 and Fischer grade 3). Clinical signs included the presence of an EVD, noradrenaline infusion and localising with right side. Candidates were asked to evaluate the patient and describe their management plan for the day.

Unspecified hospital in Melbourne

A 59 - ye ar - old woman admitted twelve days previously with a WFNS Grade 4 subarachnoid haemorrhage. Candidates were asked to examine her focussing on neurology and to present an ongoing plan of management.

2014, paper 2

Unspecified hospital in Sydney

  • 62-year-old female, day 4 in the ICU, who presented with a collapse. She was off sedation but remained unresponsive. Clinical findings included treatment with nimodipine and noradrenaline, 2 external ventricular drains with blood stained CSF and normal ICP, reduced level of consciousness, some brainstem signs, present cough and gag, temperature of 38.2 degrees. A CT brain demonstrated subarachnoid and intraparenchymal haemorrhage.
  • Candidates were asked to assess the patient to assess a likely cause for collapse and provide the current priorities in management.
2013, paper 2

Nepean Hospital

  • 43-year-old male, day 5 in ICU for an aneurysmal SAH and subsequent clipping of two aneurysms. Clinical findings included left hemiplegia, oliguria and the presence of bilateral EVDs and a nimodipine infusion. Candidates were asked to identify why he was slow to wake. Discussion points included interpretation of CT brain and CSF microscopy, causes of decreased level of consciousness and management of vasospasm.

Liverpool Hospital

  • 55-year-old female, day 3 ICU, following SAH secondary to aneurysmal bleed. Clinical findings included an intubated, awake, responsive patient with a dense left hemiplegia and the presence of an EVD, arterial puncture site at the groin and a nimodipine infusion. Candidates were told that she had presented post collapse 3 days earlier and were asked to examine her neurological system. Discussion points included interpretation of the CT brain and ECG, the differential diagnosis for this patient and the management of SAH including complications and prognosis.
2012, Paper 1

Royal Brisbane Hospital

  • 61-year-old day 3 with sub-arachnoid haemorrhage. Candidates were asked to assess her and determine a cause for her presentation with GCS 9. Discussion topics included grading of SAH, underlying causes and prognosis and approach to weaning.

Princess Alexandra Hospital

  • 70-year-old female day 10 with grade III sub-arachnoid haemorrhage complicated by hydrocephalus, seizures, severe vasospasm and extensive right MCA infarction, now febrile to 39 o C. Candidates were asked to assess her neurological status, interpret the CT scan of her head and discuss management of her fever.

Princess Alexandra Hospital

  • 18-year-old female day 5 with grade V subarachnoid haemorrhage complicated by intracranial hypertension, management of this including therapeutic hypothermia, and aspiration pneumonia. Candidates were told she had been found unconscious and were directed to assess her neurological status. Discussion included differential diagnosis, aspects of therapeutic hypothermia and DVT prophylaxis
2011, Paper 1

Westmead Hospital

  • 31-year-old female admitted to ICU with SAH secondary to ACOM aneurysm, treated by coiling. Background history included coarctation of the aorta repaired in 1994 and congenital bicuspid aortic valve.

Liverpool Hospital

  • Female with grade IV SAH from PCOM aneurysm treated by coiling and complicated by temporal infarct and recurrent hydrocephalus. Current status unresponsive with right hemispheric infarct, some absent brain stem reflexes and likely to progress to brain death.

Liverpool Hospital

  • Female with traumatic SAH and cerebral contusion. History of alcohol abuse. Re-intubated for agitation and confusion, currently has aspiration pneumonia.

Liverpool Hospital

  • Female with right MCA SAH awaiting coiling. Intubated on minimal support, left hemiparesis, agitated.
2010, Paper 2

Royal Adelaide Hospital

  • 79 year old male – D3 post Grade 5 SAH. Aneurysm coiled within 48 hrs of presentation. Candidates asked to perform a neurological examination and asked to discuss investigations and management of SAH, spasm and hydrocephalus.
2010, Paper 1

Alfred Hospital

  • A young man found collapsed at home following a SAH. Patient ventilated, EVD in place, reduced GCS. Candidates were asked to assess neurology and discuss SAH and its complications and management.
2009, paper 1

Royal Brisbane Hospital

  • A 45 year old male presented with unconsciousness 10 days ago. CT scan showed extensive SAH. Candidates were asked to assess neurological state and outline plan of management

Princess Alexandra Hospital

  • Gd V SAH ACOM aneurysm Severe neurogenic pulmonary oedema and shock over first 5 days precluded coiling
    Aneurysm remains unsecured
    • Identification of cause of collapse
    • EVD
    • Blood stained CSF
    • -Raised A-a gradient
    • Nimodipine infusion
  • Areas of weakness identified by examiners:
    • Inability to perform a proper CNS examination
    • Not being able to state a clear GCS
    • Missing the presence of an EVD
    • Lack of a management plan: - family discussion, prognostication
2008, Paper 2

Unspecified hospital

  • A 32 yr old lady with vertebral artery dissection and SAH. Candidates were asked to perform a neurological examination.
2007, Paper 2

Unspecified hospital

  • A young man with traumatic head injury – cerebral contusions and traumatic subarachnoid hemorrhage, and persistent fevers, Discussion – on ICP management, cause of fevers.