Subarachnoid haemorrhage requiring transfer — FFICM MCQ

Correct answer: B — Secure the airway before transfer

The correct answer is B, secure the airway before transfer. A falling GCS from 14 to 10 with repeated vomiting signals loss of protective airway reflexes and a high aspiration risk, and inter-hospital transfer of a patient likely to deteriorate further without a secured airway is dangerous, especially with 90 minutes travel time. UK transfer guidance is explicit that a patient with reduced consciousness must have the airway assessed and, if necessary, secured before any onward journey, since airway compromise or vomiting en route cannot be safely managed in a moving vehicle. Intubation and controlled ventilation also allow tighter control of PaCO2, which matters in subarachnoid haemorrhage where hypercapnia raises intracranial pressure and hypocapnia risks cerebral ischaemia. This makes airway control the immediate priority over any other intervention listed. Why the other options are wrong: A, transfer immediately without intubation: this exposes the patient to airway loss or aspiration during a 90 minute unmonitored journey, which is precisely the scenario transfer guidance warns against. B, give oral nimodipine and wait on the ward: nimodipine is a vasospasm prophylaxis agent, not an emergency intervention for a falling GCS, and oral dosing is inappropriate and unsafe in a vomiting, obtunded patient with reduced airway control. D, lower systolic BP below 90 mmHg: aggressive hypotension in acute subarachnoid haemorrhage risks cerebral hypoperfusion and worsens ischaemic injury; blood pressure here is only modestly elevated and does not require aggressive lowering. E, perform lumbar puncture before transfer: the diagnosis is already confirmed on CT, so lumbar puncture is unnecessary and is contraindicated with a falling GCS because of the risk of coning from raised intracranial pressure. Key point: any patient with subarachnoid haemorrhage and a falling GCS with vomiting needs definitive airway protection before transfer, since airway compromise cannot be safely rescued en route.

Reference: Faculty of Intensive Care Medicine and Intensive Care Society, Guidance on: The Transfer of the Critically Ill Adult (2019), section on airway assessment and securing before transfer, https://www.ficm.ac.uk/sites/ficm/files/documents/2021-10/Transfer_of_Critically_Ill_Adult.pdf