Cushing's Triad

[AnthonyM83]

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.

So, how would you differentiate them? Tension pneumothorax will have a sharp pain and quickly get progressively worse? Pericardial effusion....decreased lung sounds?

[AnthonyM83]

I have this little "Quick Reference to Critical Care" book my Diepenbrock (only ways I'd know there was even such thing as Cushing's Reflex...too advanced for our EMT class I guess...grrr)

Anyway, it lists it like this:

1. Bradycardia

2. Hypertension (with widened pulse pressure)

3. Bradypnea (often irregular)

I know 140 isn't too high a BP, but he had more than a bit of blood loss. But I'm not sure....I guess the best way would have been to track his VS...but I was driver...I just heard the report as we wheeled him into ER.

[Ridryder 911]

First. Beck's triad is occurring from tamponade in the pericardium. It can be produced as little as additional 10 ml and V-fib can be caused as little as 30ml of blood or fluid. Remember, what is occurring when this happens. The heart is being confined, thus pressure is being induced or ejection and refill. Remember Starling's Law ?

Becks triad will have a "narrow pulse pressure" with lowering arterial pressure, because the inability to fill and JVD will occur due to increased venous pressure from right heart problems as will you have potential muffled heart tones.

I have seen Beck's Triad and the main point of catching it is M.O.I. , D.O.R.F. sign (Ford spelt backwards..steering wheel imprintl...lol) sternal bruising or echymoses of ribs as well, and muffled heart tones, JVD, and narrowing pulse pressure. Usually, if you see the pulse pressure changed, it is getting very serious and they need pericardialcentesis in a hurry. As well, you might see ECG changes of ischemia and ectopi.

Since most services do not perform such, recognition of it is the crucial part to notify ahead for the receiving ER to be prepared.

Tension Pneumo is occurence of the lung. It inly affects the heart in the later stages (if one makes it that far) by pushing the mediastianal area (heart, trachea, etc..) over from the increased air in lung pleuritic area. Now, it can produce JVD because again, it is compromising the filling of the heart by pushing it to the side.

So, yes they are completely different and yet, they may have a tension pneumo and a tamonade at the same time.. we can correct a tension pneumo easy enough.

p.s. the respiratory breathing in ICP is sometimes referred to as Biot's respiratory pattern...no to be confused with central neurogenic hyperventilation pattern.

R/r 911

[firefighter523]

Rid, I will tell you that pericardial tamp is caused not by a steering wheel to the chest, but usually from penatrating injuries. I guess what I am saying, is that my field diag would lead me more towards myocardial contusion, if the only suspected injury was from a steering wheel to the chest.

BTW..... on the MICU, you would be very hard pressed to hear muffled heart sounds, you might want to look for the "JVD, clear lungs, and HYPOTENSION instead,........ with a "penetrating injury".

Getting back to the Cushings thing. I also would not suspect cushings if someone was shot in the head. "Kelly's Doctine" points out that the cranial vault consist of very tightly packed brain tissue, CSF, and blood. If you upset that balance, you might be on your way to Cushings. You usually will have a CLOSED vault when you manifest Cushings, not a GSW....

[AZCEP]

Apply enough force and the nature of the insult becomes immaterial. How do you end up with tamponade following an effusion, if there has to be penetrating trauma?

The closed head is not an absolute either. If the pressure exceeds the capacity of the structure to reduce it, Cushing's will resutl.

[firefighter523]

AZCEPT, lets look a little at A&P, the pericardial sac is closed, if you have a penetrating insult to that area it usually fills with blood. A sharp blow to the sternum will not usually cause the sac to be compromised. A knife will. Myocardial contusion is my path....

I can never say never with anything, nor can anyone else I guess. You very well could manifest "I guess" with cushings from a penetrating wound, doubt it though, I have never seen it, probably because it is a late sign. They usually see it days after an insult in the Trauma Neuro Unit, if they make it that far.

[AZCEP]

Yes, the pericardial sac is closed, but the damage to the underlying vasculature causes the tamponade. Blunt trauma can be damaging enough to cause it.

http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Abstract

www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16302943&dopt=Abstract

bja.oxfordjournals.org/cgi/content/full/87/2/309

Just a few examples of a phenomena that doesn't actually happen, eh?

Small caliber GSW is one example of a penetrating injury that can create a Cushing's response. What would you consider a skull fracture to be? Blunt or penetrating? Apply enough force to the skull to fracture it, and the bone fragments will enter the soft tissue underlying it, and the Cushing's response will result.

[chbare]

In addition, microvascular changes and the immune response to injury can lead to additional fluid acumulation.

Take care,

chbare.

[firefighter523]

People die of blunt cardiac trauma because of chamber rupture, not tamponade, they usually die on scene, and a needle will not help them. You presented a "1" person out of thousands that have died from blunt tamponade. Penatrating injury, aside from a disease pathology is the leading cause of pericardial tamp, because of the breach of the membrane...

[Ridryder 911]

Rid, I will tell you that pericardial tamp is caused not by a steering wheel to the chest, but usually from penetrating injuries. I guess what I am saying, is that my field diag would lead me more towards myocardial contusion, if the only suspected injury was from a steering wheel to the chest.

BTW..... on the MICU, you would be very hard pressed to hear muffled heart sounds, you might want to look for the "JVD, clear lungs, and HYPOTENSION instead,........ with a "penetrating injury".

Getting back to the Cushings thing. I also would not suspect cushings if someone was shot in the head. "Kelly's Doctine" points out that the cranial vault consist of very tightly packed brain tissue, CSF, and blood. If you upset that balance, you might be on your way to Cushings. You usually will have a CLOSED vault when you manifest Cushings, not a GSW....

I do agree there are more tamponade related injuries from penetrating injuries but with the indications of Beck's Triad in trauma one cannot exempt it. Yes, myocardial contusions will cause tamponade too as well and not as higher incidence of myocardial rupture. I agree there is a higher incident of myocardial rupture, but doubtful any symptomology will resemble Becks configuration. Since the papillary muscles are usually torn and a possible ventricular wall disruption occurs, as well as more than one chamber is usually involved, one usually sees a dead patient.

I disagree however not being able to auscultate heart tones, ones needs to possible choose better devices or use a doppler system if too much ambient noise is present. Personally, I have no problems auscultating heart tones as well as bruit's, bowel sounds etc... in the field setting. We do carry doppler for determination of true PEA as well as vasculature perfusion and of course a flat head for fetal heart tones in the event of inability to auscultate.

R/r 911