# Cushing's triad



## Anjel (Feb 8, 2011)

As a basic. 

What is the most appropriate pre hospital care for someone you suspect to be exhibiting the signs of the Cushing's triad?

I am writing a paper and would like some of your thoughts. 

If an ALS peeps see this and want to respond with what they would do, then by all means go ahead. 

THANKS! B)

p.s I hope i put this in the right category haha


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## J. Burdett (Feb 8, 2011)

Very rarely will you ever get to see all three since we typically don't have pt's for that long. The only time I witnessed all three together was a very bad off pt w/ meningitis.

As a basic your primary concerns should be expeditious transport, packaging of the pt, and suctioning of the airway. 

As far as packaging is concerned, if it is trauma induced, you are more than likely going to immobilize the pt (If the trauma was enough to cause a mass effect brain injury it would be enough to compromise the structural integrity of the spine also, unless it's penetrating trauma.) I would either not use a cervical collar at all or apply it loosely since it could decrease venous return which would further increase the ICP .

In the trauma situation assisted ventilation should be carried out by a medic and it would be up to them if they decided to bypass autoregulatory functions by hyperventilation in a attempt to "slow down" the ICP.


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## usalsfyre (Feb 8, 2011)

Anjel1030 said:


> As a basic.
> 
> What is the most appropriate pre hospital care for someone you suspect to be exhibiting the signs of the Cushing's triad?
> 
> ...



Homework assignment?

First ask yourself what Cushing's Triad is indicative of? Cause your not treating the symptoms, but the underlying physiologic disruption. What is the appropriate treatment for that?


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## Anjel (Feb 8, 2011)

usalsfyre said:


> Homework assignment?
> 
> First ask yourself what Cushing's Triad is indicative of? Cause your not treating the symptoms, but the underlying physiologic disruption. What is the appropriate treatment for that?



Yea its homework. I know its from icp. I wouldn't elevate the feet. But would backboard and possibly elevate the head. If from trauma I would follow my protocols and c-collar. If the resp were too low or too high then I would consider bagging. But at the bare minimum give them 15 l/min nrb. 

Is there anything else? Or should I do something different? I'm trying to think outside the box and make the paper some what interesting.


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## usalsfyre (Feb 8, 2011)

Anjel1030 said:


> Yea its homework. I know its from icp. I wouldn't elevate the feet. But would backboard and possibly elevate the head. If from trauma I would follow my protocols and c-collar. If the resp were too low or too high then I would consider bagging. But at the bare minimum give them 15 l/min nrb.
> 
> Is there anything else? Or should I do something different? I'm trying to think outside the box and make the paper some what interesting.



Pretty well can't think of anything. After you complete your class and pass the certifying exam I'd advise you to look up hyperoxic injury. Please don't before that time though.


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## J. Burdett (Feb 8, 2011)

Anjel1030 said:


> Or should I do something different? I'm trying to think outside the box and make the paper some what interesting.



Forget the NRB.... If they present w/ Cushing's Triad they are going to need assisted ventilation. Can basics put in a airway adjunct? If so, throwing in a OPA should be a priority if a ALS provider is not on scene.

To make it interesting research some the million or so diseases that can cause ICP. When someone mentions ICP people automatically think trauma.


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## usalsfyre (Feb 8, 2011)

J. Burdett said:


> Forget the NRB.... If they present w/ Cushing's Triad they are going to need assisted ventilation. Can basics put in a airway adjunct? If so, throwing a OPA should be a priority if a ALS provider is not on scene.
> 
> To make it interesting research some the million or so diseases that can cause ICP. When someone mentions ICP people automatically think trauma.



While end of the road herniation will need mechanical ventilation sooner rather than later, are you simply assuming their respiratory effort will always be inadequate?


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## J. Burdett (Feb 8, 2011)

usalsfyre said:


> While end of the road herniation will need mechanical ventilation sooner rather than later, are you simply assuming their respiratory effort will always be inadequate?



I wouldn't really call it assuming if a pt presents w/ irregular respiratory functions associated w/ ICP (particularly Cheyne Stokes) the periods of apnea and the decrescendo respirations would definitely require assisted ventilations.


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## Anjel (Feb 8, 2011)

usalsfyre said:


> Pretty well can't think of anything. After you complete your class and pass the certifying exam I'd advise you to look up hyperoxic injury. Please don't before that time though.



Which class should I complete before looking that up? lol Medic? I already finished basic and am licensed. I am starting medic in the fall. This class is "Extended basic". 

As for you being a medic. Besides possibly intubating and starting a line (if you would do that?) is there any meds you would give this patient? Or just rapid transport?


AND



J. Burdett said:


> Forget the NRB.... If they present w/ Cushing's Triad they are going to need assisted ventilation. Can basics put in a airway adjunct? If so, throwing in a OPA should be a priority if a ALS provider is not on scene.



Is someone presenting with Cushing's always unconscious? I suppose I could do an NPA, but I don't wanna get thrown up on trying to do an OPA (Yes i know you would never put an OPA in a conscious pt i'm not trying to say you would) 

 If the person was unconscious without a gag reflex then for sure I would secure the airway, and start ventilation.


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## J. Burdett (Feb 8, 2011)

Anjel1030 said:


> Is someone presenting with Cushing's always unconscious? I suppose I could do an NPA, but I don't wanna get thrown up on trying to do an OPA (Yes i know you would never put an OPA in a conscious pt i'm not trying to say you would)
> 
> If the person was unconscious without a gag reflex then for sure I would secure the airway, and start ventilation.



More or less, if they present w/ true Cushing's Triad from a mass effect traumatic brain injury, then yes they are going to be unconscious. 

Careful w/ the NPA, especially if a basilar skull fx is suspected. OPA is your best bet!


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## J. Burdett (Feb 8, 2011)

Anjel1030 said:


> Besides possibly intubating and starting a line (if you would do that?) is there any meds you would give this patient? Or just rapid transport?



Besides the meds given during RSI + lidocaine, nope. They are going to get loaded up on mannitol at the receiving facility.


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## Anjel (Feb 8, 2011)

J. Burdett said:


> More or less, if they present w/ true Cushing's Triad from a mass effect traumatic brain injury, then yes they are going to be unconscious.
> 
> Careful w/ the NPA, especially if a basilar skull fx is suspected. OPA is your best bet!



Ok yea I agree one hundred percent. If it is trauma related. Which it very well could be. 

But like you said with the meningitis. Was that patient unconscious?


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## J. Burdett (Feb 8, 2011)

Anjel1030 said:


> Ok yea I agree one hundred percent. If it is trauma related. Which it very well could be.
> 
> But like you said with the meningitis. Was that patient unconscious?



Oh yeah. Lights out w/ posturing!


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## Anjel (Feb 8, 2011)

Hahaha ok just making sure. Yea he would of definitely got an opa from me then lol

It just sucks being a basic sometimes. Here in oakland county a basic will never get a priority 1 trauma or medical. Just psych. 

Also our medics cannot do RSI. They don't have the right meds for it. So I think they key here would just be rapid transport. Intubate if unconscious


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## MrBrown (Feb 8, 2011)

Anjel1030 said:


> Yea its homework. I know its from icp. I wouldn't elevate the feet. But would backboard and possibly elevate the head. If from trauma I would follow my protocols and c-collar. If the resp were too low or too high then I would consider bagging. But at the bare minimum give them 15 l/min nrb.
> 
> Is there anything else? Or should I do something different? I'm trying to think outside the box and make the paper some what interesting.



Have you conceptualised the physiologic alterations for raised intercranial pressure and how your treatment may or may not affect them? 

Why would you not elevate the feet and elevate the head? How are these actions going to help? 

Assisted ventilation is overrated and overused, its not without significant risk and you often end up fighting with the patient.  If oxygenation is OK resist the temptation to manually ventilate a patient.

Oxygenation and ventilation are not the same and therefore by providing assisted ventilation can cause the patient to become hypocapenic and hypercarbic.

Also if oxygenation is OK, fifteen litres of oxygen is not going to do much and maybe more harmful given that the small arterioles constrict in high normooxic or hyperoxic states which may infact increase intercranial pressure.


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## Anjel (Feb 8, 2011)

MrBrown said:


> Have you conceptualised the physiologic alterations for raised intercranial pressure and how your treatment may or may not affect them?
> 
> Why would you not elevate the feet and elevate the head? How are these actions going to help?
> 
> ...



I would not ventilate unless resp were inadequate. I would not give the high flow o2 unless the patient needs it. I would not elevate the feet because that would be helping the blood flow back the brain faster than normal which could increase icp. I would elevate the head to possibly help some and that's what I was told to do in school. 

What would you do Mr. Brown?


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## 46Young (Feb 8, 2011)

Ventilate with the goal of an ETCO2 of 30-35. Otherwise, ventilate the adult at 12-20 if signs of herniation.


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## MrBrown (Feb 8, 2011)

Anjel1030 said:


> What would you do Mr. Brown?



Gosh "Mr Brown" sounds so formal, Brown is cool with being called Brown 

Brown would put patient on stretcher and take to hospital; provided oxygenation was adequate Brown does not see the need for supplumental oxygen.


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## zmannms (Feb 8, 2011)

From the level of basic EMT, the most appropriate care would be close monitoring and of course airway. I've seen some people suggest the use of NPA; however, with trauma, you always have to be careful. Elevating the HOB to 30degrees is always good unless contraindicated  by c-spine. 

Another consideration is hyperventalation via BVM. While this may temporarily decrease increased ICP, it's always a good thought. Once a medic is avail (depending on protocols) calcium channel blockers and IV Mannitol are the front line drugs we use to manage ICP cases.


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## J. Burdett (Feb 8, 2011)

A pt presenting w/ Cushings Triad is going to unconscious (or a GCS of 5) w/ inadequate and irregular respiratory functions. In the traumatic situation this most often is due to a uncal herniation secondary to a epidural hematoma. Per AHA supplemental O2 should be provided and for good reason.

It's a damned if you do damned if don't situation. Hyperoxia will cause increased vasoconstriction resulting in worsening CPP and cerebral ischemia but cerebral hypoxia will result in metabolic acidosis which causes vasodilation which increases CPP and ICP. This goes hand in hand w/ hypo and hypercapnia. A pt with ICP and Cushings is going to be hypoxic and hypercapnic due to inadequate and irregular respirations. This pt should be intubated w/ EtCO2 and oxygenated accordingly. If obvious signs of herniation are present (Cushings, anisocoria, posturing) I don't see a problem with a BLS provider inserting a OPA and assisting ventilations correcting the hypoxia and hypercapnia until a higher level of care takes over.


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## blindsideflank (Feb 8, 2011)

well i had a bunch of questions but ill ignore the big write up for this. how do you know this person is oxygenated well?

also everybody make sure you dont mix up hyperventilate and hyperoxygenate. not saying anyone has but i see it often. (pet peeve)


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## Anjel (Feb 9, 2011)

blindsideflank said:


> well i had a bunch of questions but ill ignore the big write up for this. how do you know this person is oxygenated well?
> 
> also everybody make sure you dont mix up hyperventilate and hyperoxygenate. not saying anyone has but i see it often. (pet peeve)



Many factors

Persons:

Color, respiratory rate and effort, spo2(not always reliable but its a tool), LOC, etc.

If the person is showing true Cushings then they will have irregular breathing. When I see that, then at my level and protocols that is my A and I will secure and airway and provide supplemental O2. How much will depend on the case and what I deem necessary.


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## blindsideflank (Feb 9, 2011)

color, this person will be pale well oxygenated or not. he will be shunting blood. if you mean cyanotic then yes i agree bag.

spo2 may read 97 percent but what is the body doing to acheive this, how much is it compensating and how is this affecting the vitals? what about secondary injuries, this is a very real possibility. hemmorhage?tamponade?pulm injuries? how are these affecting your "triad"

LOC- nobody will be mentating properly here so does that indicate NRB or BVM? what will the effect of this be? hyperoxygenation or hypocapnea?

irregular breaths- irregular doesnt necessarily mean ineffective and these pt's can had very strange breathing patterns that seem great than 10 seconds later then really shallow/deep or tachy/brady. whats acceptable?

those are some of my questions... I go NRB on these pt's (head injuries, dont really see the whole triad very often) and wait for signs  that i need to bag. traumas dont seem to need it as often as strokes do for me..funny now that i think about it


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## J. Burdett (Feb 10, 2011)

blindsideflank said:


> color, this person will be pale well oxygenated or not. he will be shunting blood. if you mean cyanotic then yes i agree bag.
> 
> 1.) spo2 may read 97 percent but what is the body doing to acheive this, how much is it compensating and how is this affecting the vitals? 2.) what about secondary injuries, this is a very real possibility. hemmorhage?tamponade?pulm injuries? how are these affecting your "triad"
> 
> ...



Those are some excellent questions!

1.) SpO2 can be the devil! It is a great tool but not without it's flaws. Perfect example was a pt of mine yesterday. Pt presented w/ respiratory distress- respirations 28 labored and bi-lateral lungs presented w/ rales (hx CHF). SpO2 read 92%....

The pt presented w/ a sympathetic response. Sinus tach around 110 (pt was also on a beta blocker), skin ashen in color w/ pale conjunctiva and mucosa, cool, slight diaphoresis, and cyanosis was noted to her fingertips. The pt's increased respiratory rate and exertion were maintaining the O2 saturation but a pt can only do that for so long....

Yes, shock will throw vitals askew, especially if you go in expecting to see vitals associated w/ a certain condition (ex- Cushings Triad). If a pt has head trauma think ICP, regardless of the vitals.

2.) Secondary injuries also will debunk any predetermined diagnosis based on "syndromes" that rely on a vital sign like Cushings or Becks. Most pt's w/  significant head trauma or thoracic trauma w/ be treated as multi-system trauma and present as such.

3.) If a pt is unconscious/unresponsive an airway w/ assisted ventilations will be provided. A BLS provider should insert a basic adjunct and assist ventilations if the unconscious/unresponsive pt presents w/ respiratory distress or respiratory failure. The pt will be hyper-oxygenated due to the supplemental O2 but that's the point. To be ahead of the 8 ball. Hypocapnia can only be determined by pre-hospital by ETCO2. If you hyperventilate a pt they will be hypocapnic. Obvious signs of brain herniation should be the only time this method of assisted ventilations should be utilized in a attempt to reduce or "slow down" ICP. Medical control should be contacted before preformed unless a protocol is in place.

4.) Irregular or inadequate is not acceptable. Every pt is different and if the pt appears to be experiencing inadequate tissue perfusion from such, then assisted ventilations should be considered/preformed.


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## Anjel (Feb 10, 2011)

So as a basic... Can I really worry about a patient becoming hypocapnic? I mean I've never even been taught to worry about that yet. lol i wasn't even sure what it meant. But I'm assuming too much or too little co2?

I was taught to never withhold o2 from anyone that needs it. Even with a chronic COPD. Although giving them too much o2 can shut down their respiratory drive. If they are turning blue and not adequately perfusing then I would give o2 via a NRB. 

And as I stated before in my little disclaimer....spo2 is just a tool and not always reliable. 

Any pt who becomes unconscious is considered to not be able to maintain their own airway. So they would get an OPA and maybe BVM depending on the situation. 

Someone who is conscious will either get an NPA (if there is no trauma) and they will for sure get o2 in some form or another and possibly the BVM. Untill I can get them to ALS or the hospital. Either or. 

That's what I know how to do. So I am going with that. 

Am I wrong?


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## blindsideflank (Feb 10, 2011)

angel, i am a paramedic student right now so i bounce around between the the basic and advanced forums. you are right that you shouldnt really have to worry about hypo (HYPO means......)capnea but it is a valuable concept to understand at any level. take a bit of time to look it up and oxygen/hemoglobin dissociation curve.

id assume u dont have any protocols involving bagging a head injured patient with supected impending brainstem herniation so dont worry about that.

your treatment is spot on. the only thing i might want to add is that the whloe COPD/respiratory drive thing is (in my opinion) overstated. It can happen but doesnt often, that said dont listen to some guy on the internet vs what you have been taught by a text and your teachers.

and to J. Burdett... i agree 100% with your post. i meant to state my questions  as more of an "ask yourself" type question but your reply ended up giving me a great read. thanks


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## usafmedic45 (Feb 10, 2011)

Anjel1030 said:


> As a basic.
> 
> What is the most appropriate pre hospital care for someone you suspect to be exhibiting the signs of the Cushing's triad?
> 
> ...



Drive quickly to somewhere with neurosurgical capability.


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## trustnobody (Feb 17, 2011)

remember this when considering increased ICP- hyperventilating a pt with increased ICP will lower thier PaCO2 and cause cerebral vasoconstriction, thus minimize brain swelling- which we want. This is an important intervention as a BLS provider. Also, if it is in youre protocol, monitor ECG along with (obviously) Sp02.
'Cushings relex' will present only in the early stages of increased ICP. More sever ICP will present with compensatory vital signs. +HR, +resps, -BP (opposite of cushings reflex)


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## usalsfyre (Feb 18, 2011)

trustnobody said:


> remember this when considering increased ICP- hyperventilating a pt with increased ICP will lower thier PaCO2 and cause cerebral vasoconstriction, thus minimize brain swelling- which we want. This is an important intervention as a BLS provider. Also, if it is in youre protocol, monitor ECG along with (obviously) Sp02.
> 'Cushings relex' will present only in the early stages of increased ICP. More sever ICP will present with compensatory vital signs. +HR, +resps, -BP (opposite of cushings reflex)



Hyperventilation is pretty controversial as to whether it helps or hurts.

I think your confused, Cushings Triad is a very late sign, i.e. herniation. What you see next is the vital signs go absoloutely haywire (massively increased or decreased HR, extreme hypertension, very very odd depressed respiratory patterns) followed a couple of minutes later by the absence if vital signs.


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## lightsandsirens5 (Feb 18, 2011)

Anjel1030 said:


> As a basic.



As a Basic, eh?



> What is the most appropriate pre hospital care for someone you suspect to be exhibiting the signs of the Cushing's triad?



Diesel.



^_^


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## Anjel (Feb 18, 2011)

usalsfyre said:


> Hyperventilation is pretty controversial as to whether it helps or hurts.
> 
> I think your confused, Cushings Triad is a very late sign, i.e. herniation. What you see next is the vital signs go absoloutely haywire (massively increased or decreased HR, extreme hypertension, very very odd depressed respiratory patterns) followed a couple of minutes later by the absence if vital signs.



ha ok this is what I thought. I was starting to second guess myself for a minute. 



lightsandsirens5 said:


> Diesel.
> 
> 
> 
> ^_^



HAHAHAHA pretty much. Everything I have read about this is you're damned if you do and damned if you dont. So PUHA!


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