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 Table of Contents  
Year : 2023  |  Volume : 4  |  Issue : 1  |  Page : 95-96

Cascade concept: Situations where an unexpected finding can lead to inappropriate handling in neurocritical care

1 Department of Critical Care Medicine, Physicians Regional Medical Center, Naples, FL, USA
2 Department of Neurosurgery, Bhopal, Madhya Pradesh, India
3 Department of Medicine, Universidad Simon Bolivar, Barranquila, Colombia
4 Latin America Council of Neurocritical Care (CLaNi), Cartagena, Colombia

Date of Submission17-Mar-2022
Date of Decision24-Aug-2022
Date of Acceptance08-Sep-2022
Date of Web Publication17-Nov-2022

Correspondence Address:
Dr. Luis Rafael Moscote-Salazar
Latin America Council of Neurocritical Care (CLaNi), Cartagena
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_22_22

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How to cite this article:
Janjua T, Agrawal A, Montaño-Bayona HA, Moscote-Salazar LR. Cascade concept: Situations where an unexpected finding can lead to inappropriate handling in neurocritical care. J Med Evid 2023;4:95-6

How to cite this URL:
Janjua T, Agrawal A, Montaño-Bayona HA, Moscote-Salazar LR. Cascade concept: Situations where an unexpected finding can lead to inappropriate handling in neurocritical care. J Med Evid [serial online] 2023 [cited 2023 Jun 7];4:95-6. Available from: http://www.journaljme.org/text.asp?2023/4/1/95/361499

As Edward O. Wilson in his book ' The Origins of Creativity' said: '…one wrong turn, one misstep of evolution, even a single unfortunate delay in an evolutionary adaptation, could have been fatal (for a species)'.[1] This is a cascade effect. The cascade effect is a well-known phenomenon in various life scenarios, and medicine is no exception. It is defined as a series of events where the outcome can lead to negative end effects. Two circumstances in clinical medicine can lead to the cascade effect, under or overdiagnosis by the physician. This can be also the excessive concern of the patient or their relatives about the outcome of the disease. Physicians cannot create conditions that lead to the deterioration of their patients. Although medical practice activity leads to results with immense variables that can affect the outcome. Physicians are educated that they must do more for the patient to achieve the results; this may include investigations and treatment modalities. The teaching of prudence may not be there. This can lead to a single mistake and circumstance that can even cause permanent injury or even death to our patients with the respective ethical and legal repercussions.

We propose various mitigation strategies so that the neurointensivist acknowledge this phenomenon and avoid unaccepted outcomes. The most important clinical situation where this can happen is the management of severe traumatic head injury. Monitoring of severe head trauma based on subjective classifications of cerebral oedema that may lead to intraparenchymal hematoma. Placement of intracranial monitoring at the bedside is not without risk and procedure-related haemorrhage will lead to the complexity of the life-threatening situation. This is mitigated with an objective assessment with close neuro checks, scoring systems to predict who will benefit from multimodal monitoring, early surgical intervention versus 48 h post-trauma surgery and critical care management of other organ systems including acute respiratory failure. Initiation of hypertonic saline solution in severe traumatic brain injury without an actual high intracranial pressure or severe cerebral oedema that leads to severe hypernatremia, hyperchloremic acidosis, acute pulmonary overload, progressive cardiac failure and renal injury. Using hyperventilation to induce respiratory alkalosis which in turn leads to reduced cerebral blood in severe brain trauma without clear evidence of severe intracranial hypertension will lead to impaired autoregulation. The cerebral metabolic activity, oxygen extraction ratio and venous outflow all will be impacted. This might lead to acute ischaemic strokes, autoregulatory failure causing haemorrhage and rebound worsening cerebral oedema. Hospitalisation and using neurocritical care resources for a mild case of traumatic brain injury can lead to unnecessary investigations, treatments and eventually complications like new infections. Elderly patients with traumatic patients are at higher risk of this and require closer monitoring in neurointensive care. The use of polypharmacy in this class of traumatic brain injury population will lead to side effects and eventual impact on the outcome. [Figure 1] suggests what happens in the cascade effect inside neurointensive care.
Figure 1: Steps of cascade effect in neurointensive care

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In conclusion, the cascade effect is quite real in neurointensive care, awareness is required and a clear understanding of how to avoid it. Furthermore, there is a need for clear checks and reviews like daily multidisciplinary rounds with repeat visits after a major intervention to confirm that the decision was the right decision for the intervention. There is a place for formal education during the training for the physicians in their neurocritical care fellowship to address the cascade effect.

  References Top

Wilson EO. The Origins of Creativity. 1st Edition.: Liverlight Publisher;. 2017. p. 77.  Back to cited text no. 1


  [Figure 1]


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