Cushing’s Triad

A curious set of signs that is usually indicative of the presence of inter-cranial pressure:

• A significant increase in blood pressure
• A significant decrease in heart rate
• A significant decrease in respiratory rate

If one of these is changed in any way, the other two will be affected.

A 93 year-old female, reported to have fallen sometime in the past two days. Family wasn’t sure, and they originally had the patient transported to the emergency room for “failure to thrive” as she hadn't eaten or gotten out of bed for the two days they had not seen her. Usually independent, she was exhibiting behavior that was uncharacteristic for her.

She was treated by EMS on the way to the ED as she’d complained of chest pain. Aspirin and NTG, from what we were told. An ECG showed sinus rhythm with left axis deviation and some indications of left ventricular hypertrophy. She also had some pain to her left arm and shoulder which turned out most likely to be musculo-skeletal, and she exhibited some slurred speech.

A head CT was done. It showed the presence of a significant inter-parenchymal bleed. The nurse who gave us report told us it was large. And the doc told us that while it was present, she was stable and would tolerate the ride to the hospital where we were transporting her to.

But they had no films to send. Could be that because we were transporting her to a hospital in the same network they were able to send the films electronically. At least I wouldn’t be surprised if that were how they were sent.

My partner took care of her during the trip. It was a short one, but during that time she did have some subtle but significant changes to her blood pressure and heart rate. And her speech became more slurred.

Her condition was a near textbook example of the balance of Cushing’s Triad. I’d seen it before; it is fascinating and frightening at the same time. The good news, however, is that it was a relatively short trip: a little over 3 miles in about 15 minutes because of traffic. And, she tolerated it well.

Thank goodness.