Cushing's Triad

[AnthonyM83]

I was wondering how quickly people out there have seen Cushing's Reflex manifested in physical symptoms.

We had a GSW last night. Approx 21yro male, Entrance wound to occipital, some brain matter loss, Resp: 8, BP: 140/p (seemed high for young guy with moderate blood loss), concious, but altered, some hand posturing on right side, would follow only some simple commands, eyes rolled back...don't remember the pulse rate (I was driver) but I think it was high.

Cushing's Reflex popped to mind, aka inc. ICP (Guess not a big surprise having been shot in the head).

Just wondering on average how quickly this develops. A passing EMT (whose gone through medic school) said he was told we wouldn't usually see those signs in the the field, as they're late signs. That we usually just see the rapid breathing, pulse, and widening BP as patient compensates. I think though he might have been confusing symptoms of shock with symptoms of ICP? Or does the same happen with ICP if there hasn't been too much blood loss? How quickly have you seen shock progress from a trauma progress in moderate (no excessive) bleeds.

Just trying to learn a little from this call.

Thanks.

[medic001918]

I have seen cushing's triad in the field. Time of onset for cushings is more related to the severity of the CVA and how quickly everything develops. The faster the bleed, the sooner the onset. In a subdural bleed, where the symptoms takes hours and sometimes days to develop you wouldn't see it quickly. In a subarachnoid bleed which is arterial in nature, you'd be more likely to see the symptoms develop rapidly.

As for your GSW patient, I would think that the posturing you saw and the changes were due to the physical trauma to the brain more so from an increase in ICP.

I'm pressed for time since I'm about to go to work for my tour tonight. But hopefully that helps a little. I'm sure someone else will elaborate some more.

Shane

NREMT-P

[AZCEP]

We had a GSW last night. Approx 21yro male, Entrance wound to occipital, some brain matter loss, Resp: 8, BP: 140/p (seemed high for young guy with moderate blood loss), concious, but altered, some hand posturing on right side, would follow only some simple commands, eyes rolled back...don't remember the pulse rate (I was driver) but I think it was high.

The presentation will change a bit based on the involved area(s) of the CNS. The time factor is also going to factor into this one.

Let's think this one through:

What is the occipital region of the brain responsible for?

What will happen when this area is damaged?

How is the medulla oblongata organized? Or, what functions will be affected first --> last?

Cushing's Reflex popped to mind, aka inc. ICP (Guess not a big surprise having been shot in the head).

Having the opening in the cranial vault will alleviate some of the swelling, partially mitigating the increasing ICP.

So why was his respiratory rate so slow, and his BP elevated?

How much blood volume do you have to lose to reduce the BP?

How does the body compensate for the blood loss in the mean time?

Just wondering on average how quickly this develops. A passing EMT (whose gone through medic school) said he was told we wouldn't usually see those signs in the the field, as they're late signs.

It will depend on the degree of the insult. Don't limit your view on this to the blunt/penetrating trauma patient either. A stroke (CVA) will cause the same presentations. We often don't consider them to be a head injury, but they truly are.

That we usually just see the rapid breathing, pulse, and widening BP as patient compensates.

You may have misread Cushing's triad. This looks like you've mingled Beck's and Cushing's. Equally important, but deals with a decidedly different part of the body. Cushing's triad is an elevated blood pressure/slow pulse rate/irregular or patterned breathing. Also remember, an adult human can't bleed into their cranial vault enough to cause shock. If you have a hypotensive head injury, look somewhere else.

I think though he might have been confusing symptoms of shock with symptoms of ICP? Or does the same happen with ICP if there hasn't been too much blood loss? How quickly have you seen shock progress from a trauma progress in moderate (no excessive) bleeds.

Looking for a specific time frame is a mistake. There are some sweeping generalizations that can be made, but you can't really isolate a given time that it takes to cause irreprable harm. Every patient and situation is different. The symptoms of shock do occur to these patients because they are not perfusing other organs as well.

After a traumatic injury like you've described, the body will keep the vital areas alive as long as possible, and sacrifice others. The "pecking order" is pretty much set by our DNA. The brain and heart are at the top of the priority list, the lungs, liver, kidneys somewhere lower. The GI,GU,musculoskeletal, and skin come near the bottom. The triggering event is not terribly important. The body recognizes a problem, and keeps the vital areas perfused, and the not-so-vital areas not. All of this results in the signs of shock.

Just trying to learn a little from this call.

Thanks.

I wish more would take the time to understand these things. You are most welcome.

[Ridryder 911]

Good points Azcep.. I have seen a few TBI with Cushing's Triad, and as of yet, never seen but one survive. That because emergency burr hole was able to be performed and ICP monitoring was established.

Like Azcep described there are many misunderstandings and confusion of the reflex. As he described and some others CVA can cause this as well. The amount of pressure, and degree of ICP pushing upon the pons of the brain stem, and amount of bleeding occurring.

This is why it is so essential we become more educated in advance neuro assessments than the PEARL bull sh*t , that is being taught..Which means nothing! Once we start educating EMT's on neuro assessments such cranial nerves, nystgmus, and brain perfusion and cerebral resuscitation.

So many are still performing hyperventillation and witholding fluids..

R/r 911

[SSG G-man]

I am a relatively new EMT, but always willing to learn. Can someone tell me what Cushings Triad and Becks are? I think I have heard the terms before but do not know the sins/symptoms. Thanks!

Sarge

[Medic2588]

Cushing's Triad is a group of signs that might indicate increased intracranial pressure.

1. Increased BP - to improve oxygenation to the brain to compensate for the increased pressure

2. Decreased Pulse - triggered by the pressure on the baroreceptors in the brain

3. Altered patterns of breathing - I forgot how you explain this one

Beck's Triad is a group of signs that might indicate a pericardial tamponade

1. Decreased systolic BP with a narrowing of the difference between the systolic and diastolic values

2. Muffled heart tones

3. Jugular vein distention

Devin

[SSG G-man]

Thanks! I don't mean to come off like an idiot. I just want to learn as much as I can.

[Medic2588]

Not at all SSG, that's what this site is for. The only stupid questions are those that aren't asked. Of course, we can always come up with stupid answers 8)

Devin

[AZCEP]

Medic2588 gives a good description of the two, but those are the more commonly found signs of the problems.

Beck's triad results from an inability of the blood to return and exit from the heart. Narrowing pulse pressures (decreased systolic), increased central venous pressure(JVD), and muffled heart sounds can be caused by other things as well. Pericardial tamponade is the classic textbook cause. Tension pneumothorax and pericardial effusions can also manifest Beck's.

The Cushing's triad is related to the degree of herniation on the pons. This area of the brain stem is where the chemoreceptors (respiratory center), baroreceptors (blood pressure), and cardiac center (heart rate) are found. At the top of this progression is the level of consciousness. As the brain stem herniates, the pressure shuts down the individual centers in a step wise progression.

Respiratory-->blood pressure-->heart rate-->LOC. It is possible to have a situation that involves them in the opposite direction, but this is less common.

[fiznat]

Interesting subject.

I was talking about this with another medic a few weeks ago, and she insisted that peds will show Cushing's signs later than an adult would. She cited the often-preached fact that peds tend to compensate longer than adults do, and then crash. Still though, like others have said, I imagine ICP (and the resulting cushing's symptoms) would manifest at a rate almost directly in relation to the speed of the bleed/insult. A patient with a fast bleed will present with changes fast, while one with a slow bleed will present slower. ...Regardless of age

Perhaps this medic is confusing shock symptoms with ICP symptoms? Any thoughts?