Neurocritical Care - exam-focused guide
Neurocritical Care covers ICP and CPP management, ventilation, sedation, seizures, status epilepticus and brain death. The exam tests tiered therapy and physiological targets.
Core rules
- ICP normal is about 5–15 mmHg; treat sustained ICP >22 mmHg. CPP = MAP − ICP; target 60–70 mmHg in adults after TBI.
- Tiered therapy: head elevation, adequate sedation/analgesia, temperature control, normocapnia, osmotic therapy, CSF drainage, then decompressive surgery or barbiturate coma.
- Hyperventilation lowers PaCO2 and ICP within minutes by cerebral vasoconstriction, but prophylactic use causes ischemia; reserve it for acute herniation.
- Status epilepticus: benzodiazepine first, then levetiracetam, phenytoin or valproate; refractory cases need intubation and anaesthetic agents.
- Brain death requires irreversible coma, absent brainstem reflexes, apnea and exclusion of confounders such as hypothermia, drugs and metabolic disturbance. Follow local protocol.
- Fever, hyperglycemia and hyponatremia worsen brain injury; treat aggressively.
Worked example: A ventilated TBI patient has ICP 30 mmHg and MAP 70 mmHg; CPP is 40 mmHg. Sedation and analgesia are optimized, head is elevated, normocapnia confirmed and mannitol given. If ICP remains high, CSF drainage and decompressive surgery are considered. Hyperventilation is used only as a bridge to definitive treatment.
Traps: using prophylactic hyperventilation; targeting CPP without treating ICP; missing non-convulsive status; declaring brain death before excluding drugs and hypothermia; ignoring sodium and glucose.