Cushing's Triad

[Ridryder 911]

Cushing and shock would represent the opposite signs. (shock < BP, > pulse: Cushing >BP , <pulse) I do agree kids crash faster and the reason being they do not present the ability to talk and give information about their LOC etc.. that is why it is essential that we recognize the m.o.i. and a detailed pediatric neuro assessment.

As well, I have seen more prominence in projectile vomiting with children over adults in number. Remember that the child's head in proportion of body mass is much larger and cause of this have more head injuries. (Bobble head theory) Watch a child fall, they usually will strike the head reason due to the weight in proportion of the rest of the body. Now, in theory place this in a projectile situation such as non-restrained MVC.

My suggestion is on real MVC with children non-restrained treat aggressive for potential head injuries until ruled out.. i.e suction near-by, IV lifeline in place.

It is much easier to perform if things are in place then when the sh*t hits the fan..!

R/r 911

[mobey]

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.

R/r 911

=D>

I totally agree!!

I had a hemmoragic stroke not long ago and was presenting with nystgmus. I was pissed that I didn't know what it was when I saw it. I called up one of my paramedic buddies and he showed me how to quickly test most of the 12 nerves and some other tips. This should be a standard neuro exam as far as I am concerned.

[Just Plain Ruff]

Hey Mobey, care to post what the quick test your medic friend showed you. I am sure it will benefit most of those of us here.

[mobey]

Please keep in mind I am not claiming to be testing all 12!! Please add as you see fit.

PCP/EMT school taught to assess:

PERRL

Facial droop

Equality of smile

Grip strengths

Arm drift

I have added:

Directions of gaze. left, right, up, down.

Have the patient recite "you can't teach an old dog new tricks"

Raise both eyebrows

Ask the Pt. to swallow and assess if extra effort was needed

Stick out tongue

Shrug shoulders

I also do strength tests on Ext. and draw a number on the ankle and ask the patient to tell me what it is. Keep in mind I have an exceptionally long transport time so I can assess all I want.

I was also shown how to test some reflexes and have tried it a few times to pass the time.

I am still building on my assesments and any imput is appreciated.

Mobey

[Ridryder 911]

I have been doing CNS test for at least 25+ years, after reading Bledsoe's advanced paramedic skills book, (when he was in med school). It is simplistic and definitely not as detail as a good exam, but is better than nothing. I got tired of not knowing early signs of neuro porblems, I don't want to wait for my patient to crash.

Basically, it can be performed in < 1 minute, but can tell you a life's worth ! It is so simple, we should be teaching this in Basic EMT !!!

Cranial Nerve Examination 1.

Cranial nerve I Olfactory: Ask patient about smelling. Keep eyes closed one nare pushed closed, smell w/each nostril Test with different smells such as alcohol pad and cologne or other fragrance

Cranial nerve II.: Optic nerve

This is when we check for pupillary reflexes. Light should be shined from outside corner to pupil noting reflex (brisk,etc) I keep a small Snellen, eye chart with me, that has colors and different size print. But I used to keep a colored paper advertisement, I laminated and have them read it & tell the colors.

visual acuity

visual field

color vision

optic disc appearance

III Occulomotor - eye movement. Look for ptosis (drooping eyelid), note the appearance of the eyes, and check for ocular alignment (the light source reflection should fall at the same location on each eyeball).

IV Trochlear Nerve: Next, test extraocular range of motion by having the patient follow one of your fingers through the six principal positions (called Cardinal movements) of gaze (make an "H" pattern). Note any misalignment of the eyes or complaints of diplopia or unable to focus. When specifically evaluating CN 3 during testing, note adduction (medial rectus) Moving eye inwards, depression while abducting (inferior oblique) moving eye towards the side, and elevation (superior rectus and inferior oblique) moving eye up and down, ptosis (III nerve) droopy eyelid. This can be done simply by and pupil reaction to light (II & III nerve) Light should be shined from outside corner to pupil noting reflex (brisk,etc) and if the opposite pupil reacts as well.

V. Trigeminal Nerve

The trigeminal nerve supplies both sensory and motor fibers to the face and periorbital (around the eyes) area. The afferent sensory fibers separate into three divisions and carry touch, pressure, pain, and temperature sense from the oral and nasal cavities, and the face. Motor efferent fibers function to innervate several facial muscles, including the muscles of mastication (chewing).

The sensory portion of the trigeminal nerve is commonly tested by examining the how intact and sensitive of pain and light touch sensation from all areas of the face (forehead, cheek, and jaw). Ask the patient to close his/her eyes, a 4 X 4 or the cotton from your baby asprin bottle, it is lightly touched to one side of the forehead. The 4X4 or cotton is then touched to the opposite side and the patient is asked to compare sensations. A sharp object can be used (cap of an ink pen) in the same manner when testing for pain symmetry. The test is then repeated on the cheek and jaw line. Testing the sensory distribution of the trigeminal nerve. Ask your patient to compare the sensation of light touch on both sides of the forehead, cheek, and chin.

An another test used to evaluate the trigeminal nerve is the corneal reflex test. Evaluate the reflex by gently touching each cornea with a sterile edge of a 4 X 4, and observing any asymmetries in the blink response This tests both the sensory fifth nerve and the motor portion of the seventh nerve, which is responsible for lid closure.

VI. Abducens Nerve

The abducens nerve supplies somatic efferent motor fibers to the lateral rectus muscle, which functions to abduct the eye. Have the patient follow your finger and tracing an "H" pattern tests the abducens nerve. Inability to abduct (move the eye outwards from midline) the eye indicates a possible deficit. Aneurysms, tumors, meningitis, trauma, and cavernous sinus problems.

VII. Facial Nerve

The facial nerve supplies efferent motor innervation to the muscles of facial expression, and carries sensory afferent fibers from the anterior two thirds of the tongue for taste. To test the motor division of the facial nerve, start from the top and work down. First, have the patient wrinkle their forehead and check for asymmetry. Next, have the patient shut the eyes tightly while you attempt to open them. Note any weakness on one side. Finally, have the patient smile big or snarl at you to show his/her teeth and compare the nasolabial folds on either side of the face. To detect droope

VIII: Vestibulocochlear NerveThe eighth cranial nerve carries two special sensory afferent fibers, one for audition (hearing) and one for vestibular function (balance). The cochlear division of CN 8 is tested by screening for auditory/hearing. This can be done in the field by the medic lightly rubbing his/her fingers together next to each of the patient's ears and comparing the left and right side responses.

FYI: In addition, you may see in ER a Rhinne and Weber tests. This is why they have tuning forks (no, there not for musicals )These are easy to perform and can help differentiate conductive deficits from neurosensory lesions. The Weber test consists of placing a vibrating tuning fork on the middle of the forehead and asking if the patient feels or hears it best on one side or the other. In a normal patient, they will say that it is the same on both sides. The patient with unilateral neurosensory hearing loss will hear it best in the normal ear, and the patient with unilateral conductive hearing loss will hear it best in the abnormal ear.

The Rinne test consists of comparing bone conduction, assessed by placing the tuning fork on the mastoid process behind the ear, versus air conduction, assessed by holding the tuning fork in air near the front of the ear. Remember normally, air conduction volume is greater than bone conduction sound volume which will be dull). For neurosensory hearing loss, air conduction volume is still greater than bone conduction, but for conduction hearing loss, bone conduction sound volume will be greater than air conduction volume.

Testing of the vestibulocochlear nerve. The Weber test. The tuning fork is struck and placed in the middle of the patient's forehead. The patient compares the loudness on both sides. The Rinne test. A tuning fork is held against the mastoid process until it can no longer be heard. It is then brought to the ear to evaluate patient response.

Vestibular testing is can be used to assess brainstem function in comatose patients or in patients who report vertigo/dizziness.

Negative results can be for damage to CN 8 which can be caused by trauma, tumors, or infection and can lead to hearing loss, dizziness, loss of balance, tinnitis, and deafness.

IX: Glossopharyngeal Nerve

The ninth cranial nerve supplies motor fibers to the parotid gland and the pharynx. It also carries sensory fibers from the carotid body and taste sensation fibers from the posterior third of the tongue.

Check for a gag reflex, this can tests both the sensory and motor components of CN 9 and CN 10. This involuntary reflex is obtained by stroking the back of the pharynx with a tongue depressor or oral airway and watching the elevation of the palate (as well as causing the patient to gag).

The motor division of CN 9 and CN 10 is tested by having the patient say "ahh" or "kah. The palate should rise symmetrically and equally in the back of the oral cavity . Paralysis of the ninth nerve causes a pulling of the uvula (that thing that hangs down) to the unaffected side. The ninth, tenth, and eleventh cranial nerve pathways are close together.

So basically in the field testing the glossopharyngeal and vagus nerve. The patient sticks out her tongue and says "ahh." The palate and uvula should elevate symmetrically without deviation.

X.Vagus Nerve

The vagus nerve carries sensory afferent fibers from the larynx, trachea, esophagus, pharynx, and abdominal viscera. It also sends efferent motor fibers to the pharynx, tongue, thoracic and abdominal viscera, and the larynx. Testing of the vagus nerve is performed by the gag reflex and "ahh" test as described above.

Have the patient swallow, difficulties can be resulted from unilateral lesions affecting the vagus nerve can produce hoarseness and difficulty swallowing due to a loss of laryngeal function. Causes of unilateral lesions include trauma and from surgical procedures of the neck, aortic aneurysm, and compression due to enlarged paratracheal lymph nodes from metastatic carcinoma.

XI: Accessory NerveThe accessory nerve carries efferent motor fibers to innervate the sternomastoid (sternum) and trapezius muscles (neck muscles). The accessory nerve is tested by asking the patient to shrug the shoulders (trapezius muscles) and turn the head (sternomastoid muscles) against your hand. Palpate the patient's sternocleidomastoid muscles and feel for tension as the patient attempts to turn his/her head. (DO NOT ATTEMPT IN THOSE WITH POTENTIAL CERVICAL INJURIES!!!)

.

XII: Hypoglossal Nerve

The twelfth cranial nerve supplies efferent motor fibers to the muscles of the tongue. To test the hypoglossal nerve, have the patient stick out their tongue and move it side to side and with gloved hand or 4X4 check strength. If there is unilateral weakness, the protruded tongue will deviate towards the side of the weakness (i.e CVA)

Further testing includes moving the tongue right to left against resistance or you cna have the patient say "la, la, la."

Now, this all seems complexed, but again with practice, practice, practice.. one can perform all this in under a minute. The results will amaze you ! Especially in those with potential CVA, ICP and TBI

Good luck and practice !

R/r 911

[DwayneEMTP]

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?

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?

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.

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.

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.

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

Possibly the most valuable teaching post I've seen in months...Man...thanks for doing this AZCEP! First rate....

[AZCEP]

Glad to help. Particularly when the question(s) is/are well thought out.

Atta boy to AnthonyM83 for taking the time to ask it.

[Asysin2leads]

Okay, so before I looked stupid, I decided to review Cushing's Triad. This definition states "hypertension, bradycardia, and widening pulse pressure OFTEN ACCOMPANIED by changes in respiration". I put the caps because up until reviewing there, I thought Cushing's Triad was hypetension, bradycardia, and changes in respiratory pattern. See, even I can be wrong.

Anyway, in my opinion, things like Cushing's Triad are one of those things that needs to be commandeered and adapted for our own use. First of all, in the grand schemes of things, the specific numbers, when it comes to BP and HR, doesn't matter so much as the range and the context. For instance, if someone had a BP of 160/100 and a HR of 110 after say being in a car accident, I wouldn't immediately think along the lines of Cushing's Triad but rather along the lines of say internal hemmorhaging. However, if there BP was 180/110 and there HR was 50, and there was a signifcant mechanism of injury or AMS, or unequal pupils then yeah, I'm thinking brain herniation. So, its not so much if there BP is elevated, and they have a head injury, its if there is a mismatch between the blood pressure and the heart rate that needs to be considered, along with the mechanism of injury and other signs. In your case, I wouldn't really think 140 sys is that high, I mean the dude just got shot in the head, he'll be a little upset. I usually don't think anything is really amiss until you go above 150 systolic in a normally healthy young adult or above 180 in the elderly. But as I said before, if the guy has a 140 sys BP and a HR of 42, yeah, we could be looking at something bad.

I have seen genuine Cushing's in a handful of people. All of them are now dead. Its really a late sign and never a good one. Maybe someday they'll clear us for trepanation (look it up!) in the field and I can sling a Black and Decker cordless on my duty belt like Clint Eastwood, but until that day comes we'll just have to get them to the hospital really, really quickly.

[FireMedic65]

i thought it was narrowing pulse pressure?

[AnthonyM83]

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.

Well it was the new passer by medic who said that. I think he was confusing Cushing's triad and early signs of (compensated) shock.

It's interesting seeing things in the field for the first time...mainly b/c it's not always textbook, like shock.

I'd seen a few patients who were hypotensive, but wasn't until 3 months into it that I saw a classic presentation with the cool pale clammy skin, diminishing LOC...or the first time I saw coffee ground emesis.