Neurocritical care triad – Focused neurological examination, brain multimodal monitoring and maintaining neuro homeostasis

Intensive care is rightly described as “an art of managing intense intricacy” and this situation is further complicated in the care of patients with critical neurological illness. Brain damage directly related to an insult is primary brain injury (PBI). The cascade of pathobiological events following PBI is known as secondary brain injury (SBI). PBI is most often irreversible so, the focus of neurocritical care is to prevent, detect and manage SBI. The quintessential of neurocritical care is focused neurological assessment, appropriate neuroimaging and real time monitoring targeted at preserving neuro homeostasis. Focused neurological assessment includes a rapid examination of brain stem reflexes, five P's, identifying nonconvulsive status epilepticus and using appropriate assessment scales. Brain multimodal monitoring is employed to assess and follow the trends in intracranial pressure, brain tissue oxygenation, regional cerebral blood flow and EEG. This helps in critical decision making. SBI characterized by a series of cellular injury cascades and other secondary insults deranges the neuro homeostasis. Maintaining CPP, treating fever, good glycemic control and appropriate management of electrolyte imbalances are the cornerstones in mitigating the secondary insult to the brain.