Cushing's triad

[Anjel]

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

 

[J. Burdett]

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.

 

[usalsfyre]

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

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?

 

[Anjel]

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.

 

[usalsfyre]

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.

 

[J. Burdett]

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.

 

[usalsfyre]

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?

 

[J. Burdett]

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.

 

[Anjel]

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

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.

 

[J. Burdett]

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!

 

[J. Burdett]

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.

 

[Anjel]

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?

 

[J. Burdett]

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!

 

[Anjel]

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

 

[MrBrown]

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.

 

[Anjel]

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.

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?

 

[46Young]

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

 

[MrBrown]

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.

 

[zmannms]

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.

 

[J. Burdett]

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.