Cushing Triad in ICP and Beck’s Triad

Are you looking for trustworthy, detailed information about Cushing Triad – a classic sign of increased intracranial pressure, and Beck’s Triad in Cardiac Tamponade? These are the most popular triads in the medical world. Whether you are a nurse who is searching for a useful guide about Cushing’s triad and Beck’s triad for USMLE and other exams, or you may be a paramedic, medical personnel, or anybody interested in medical terms, today’s topic is just for you. First, we will talk about Cushing’s triad and then we will move on to Beck’s triad. So, let’s begin.

Cushing Triad is a characteristic sign of increased intracranial pressure (ICP). Beck’s Triad is a characteristic sign of acute cardiac tamponade.

cushing-triad-vs-becks-triad

 

Cushing’s Triad

All About Cushing Triad » triada de cushing, Beck’s Triad

Definition ComponentsSigns & SymptomsCausesPathophysiologyTreatmentMnemonic of Cushing Triad

What is Cushing Triad? Define Cushing’s Triad

Also known as the increased ICP triad, Cushing’s triad is defined as a set of three clinical signs of increased intracranial pressure (ICP), which includes bradycardia, bradypnea, and hypertension. Cushing’s triad is the manifestation of Cushing reflex (also referred to as the Cushing effect, the Cushing reaction, the Cushing’s phenomenon, or Cushing’s Law) – physiological nervous system response to increased intracranial pressure.

Cushing’s triad is also known as the brain herniation triad. It is the signs/symptoms developed by Cushing’s reflex.

Cushing Triad is important, but a late sign of raised intracranial pressure (ICP). The doctors, paramedics, and nurses must be looking for this condition in patients who have had a recent head injury, brain injury, neurosurgery, or anyone with a suddenly altered level of consciousness. It usually serves as a warning sign of brain herniation

Cushing’s reflex (and Cushing’s triad) can also be seen in the intravenous administration of epinephrine and other drugs of similar nature. 

Whenever a Cushing reflex occurs, there is a high probability of death in seconds to minutes. As a result, a Cushing reflex indicates a need for immediate care. Since its presence is a good detector of high ICP, it is often useful in the medical field, particularly during surgery. 

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Components of Cushing Triad Nursing Guide USMLE

Cushing’s triad is a clinical triad consists of the following vital signs:

  • Bradypnea – a change in respiration, often irregular and deep, such as Cheyne stokes
  • Systolic hypertension– Widening pulse pressure (the difference between systemic and diastolic blood pressure). Systolic blood pressure will usually be over 180mmhg
  • Bradycardia (slow heart rate) <50bpm

Other Signs and Symptoms of ICP (Cushing’s triad)

Along with 3 primary vital signs of Cushing’s triad, the following signs and symptoms are also common in ICP.

  •  Headache
  • Fixed dilated pupil (unilateral in early-stage, bilateral in the late stage of brain herniation)
  • Diplopia (double vision)
  • Seizures
  • Nausea and vomiting
  • ALOC (altered level of consciousness)

History and Etymology of Cushing Triad

The phenomenon of Cushing’s triad was first described by an American neurosurgeon, Harvey Williams Cushing (born April 8, 1869, Cleveland—died Oct. 7, 1939, New Haven, Conn., U.S.) in 1901. He was the leading neurosurgeon of the early 20th century.  Cushing’s Triad is named after him.

Harvey Williams Cushing graduated from Harvard Medical School in 1895 and then studied for four years at Johns Hopkins Hospital, Baltimore. He worked as a surgeon at Johns Hopkins from 1902 to 1912 and thenceforth he was surgeon-in-chief at the Peter Bent Brigham Hospital in Boston and professor of surgery at the Harvard Medical School. He joined the faculty of Yale University in 1933.

Cushing developed several operating procedures and techniques that are still basic to the surgery of the brain. He became the leading expert in the diagnosis and treatment of intracranial tumors.

His research on the pituitary body (1912) gained him an international reputation, and he was the first to ascribe to pituitary malfunction a type of obesity of the face and trunk now known as Cushing’s disease, or Cushing’s syndrome. He wrote numerous scientific works and received the Pulitzer Prize in 1926 for his Life of Sir William Osler (1925).



Causes of Cushing’s Triad Nursing Guide USMLE

The immediate cause of Cushing’s triad is increased intracranial pressure. There are many conditions to increase ICP. Common causes are:

  • Brain tumor
  • Traumatic brain injury
  • Stroke
  • Seizure
  • Aneurysm rupture and subarachnoid hemorrhage
  • Encephalitis (irritation and swelling, or inflammation, of the brain)
  • Hydrocephalus (increased fluid around the brain)
  • Hypertensive brain hemorrhage
  • Intraventricular hemorrhage
  • Meningitis
  • Subdural hematoma 
  • Epidural hematoma 

Traumatic brain injury and Cushing’s Triad

Traumatic brain injury (TBI) is a serious global public health problem.  Early diagnosis and management of severe TBI are crucial to reducing mortality and morbidity.

The efficacy of intracranial pressure monitoring in pediatric patients with severe TBI remains controversial; however, intracranial hypertension is associated with high mortality and worse neurological outcomes. If intracranial pressure increases after TBI, systemic blood pressure rises as a compensatory mechanism to maintain cerebral perfusion pressure.

Cushing’s triad of respiratory irregularity, hypertension, and bradycardia is a classic sign of intracranial hypertension. Hypotension in pediatric patients with severe TBI is also associated with poor outcomes due to decreased cerebral perfusion pressure. (Cerebral hemodynamic predictors of poor 6-month Glasgow Outcome Score in severe pediatric traumatic brain injury.

A study “Cushing’s sign and severe traumatic brain injury in children after blunt trauma: a nationwide retrospective cohort study in Japan” done by Tetsuya Yumoto et. al. concluded that Cushing’s triad after blunt trauma was significantly associated with BI-NSI in school-age children and young adolescents.


Cushing’s Triad Pathophysiology Patho of Cushing’s triad

How increased ICP leads to systolic hypertension?

Traumatic brain injury and ICP leads to cerebral ischemia as a result of hypoxia and decreased cerebral perfusion pressure (CPP). To compensate for the hypoxia the activated sympathetic nervous system stimulates alpha 1 and beta 1 adrenergic receptors.

The brain thinks it is helping but can actually worsen the problem. Increased blood flow to the brain causes further bleeding, swelling, and resulting ICP. The compensatory mechanisms get caught in a continuous positive feedback loop.

The body attempts to maintain mean arterial blood pressure (MABP) and cerebral perfusion pressure (CPP).

MABP = Diastolic BP + (Systolic BP – Diastolic BP)/3

CPP = MABP – CP

Normal MABP is 70-100 mmHg and normal ICP is 0-15 mmHg. Herniation occurs at a pressure above 25 mmHg. Normal CPP is 50-70 mmHg.

Why there is a slow heart rate (bradycardia)?

Bradycardia is another vital sign of Cushing’s triad. Increased ICP stimulates the vagus nerve, which contributes to a drop in the heart rate. In case of severe herniation, pressure on the medulla oblongata can cause a decrease in heart rate as well.

What causes irregular respirations?

Increased systolic blood pressure and increased intracranial pressure give rise to brain herniation. The brain herniation exerts pressure on the medulla oblongata (brain stem) – the respiratory center of the brain. The continuous pressure on it disrupts the function of the medulla oblongata and as a consequence, respirations become irregular. The disturbed respiration patterns commonly seen in Cushing’s triad are:

  • Increase and decrease in the rate of respiration with periods of apnea
  • Cheyne stokes respiration
  • “Pre death” pattern
  • Prolonged inspiratory phase followed by a shortened expiratory phase
  • Biot/Ataxic Respirations
  • Irregular with episodes of apnea



Cushing Triad Vs Shock

The best trick of remembering Cushing’s triad is to think of it as the opposite of body response to shock. In shock, there will be decreased blood pressure (hypotension), tachycardia, and tachypnea. But in Cushing’s triad increased systolic blood pressure (hypertension), bradycardia, and irregular respirations are common.

cushings-triad-vs-shock

Cushing’s Triad Treatment

Best and the only treatment for any patient with ICP/Cushing’s Triad is rapid transport to the definitive care/surgery unit because it is a medical emergency. The maximum on-scene time should be limited to 10 mins. If ICP is accompanied by an active seizure, it should be treated.

Spinal Precautions

Patients presenting with Cushing’s Triad have a high incidence of concomitant spinal cord injuries. It is necessary to maintain manual spinal immobilization until fully c-spined. Some studies have found that placement of a c collar can cause an increase in ICP. C collars are generally not form-fitting as it is placed too tightly which might reduce venous blood return away from the brain.

Oxygenation

Maintaining ETCO2 of 35-40 is vital as ETCO2 less than 25 increases the chance of mortality. As the patient can’t regulate breathing, he should be assisted in ventilation. The patient with Cushing’s triad is likely to be completely unresponsive and the intubation may become difficult or impossible. Try to place the ET tube if possible.

Hypotension

Hypotension is unlikely in the patient with Cushing’s triad. Any patient with other signs of ICP that presents with hypotension should raise your suspicion for Hypovolemia, internal or external hemorrhage, spinal injury, or distributive shock.

Posture and Positioning

The patient with Cushing’s triad should be positioned with head and trunk elevated 30-45 degrees to assist with the venous return from the head. Similarly, patients on a backboard should be elevated 15-30 degrees to facilitate drainage. Studies have suggested the use of chemical sedation of patients that are aggressive or agitated due to head injury. Researches have shown that increased stress and activity will increase ICP.


Cushing Triad Mnemonic

cushing's-triad-mnemonic


Beck’s Triad

All About Beck’s Triad in Cardiac Tamponade »

Introduction Components of Beck’s Triad Pathophysiology Mnemonic Treatment

What is Beck’s Triad? Cardiac tamponade triad

Also known as acute cardiac tamponade triad or heart tamponade triad, Beck’s triad is a collection of three classic cardiovascular signs that indicate cardiac tamponade. Cardiac tamponade is a medical emergency in which the excess fluid accumulated in the pericardial sac impairs the heart’s ability to pump blood.

becks-triad-cardiac-tamponade


Components of Becks Triad

The classical diagnostic features of cardiac tamponade (components of Beck’s Triad) are:

  1. Falling blood pressure – Hypotension (weak pulse or narrow pulse pressure)
  2. Distant or decreased Heart sound (muffled heart sounds)
  3. Rising jugular venous pressure (distended jugular veins)

Beck actually described two triads, one for acute cardiac tamponade (CT) and another for chronic tamponade.
Beck’s triad for chronic tamponade consists of jugular vein distention(JVD), ascites, and decreased heart sound (muffled heart sounds).
Beck’s triad for acute tamponade consists of jugular vein distention,  hypotension, and muffled heart sounds.

Almost 90% of patients of tamponade have at least 1 of the signs, but only one-third have all of the three signs. Furthermore, a late manifestation of cardiac tamponade shows all three signs, usually preceding cardiac arrest.

History and Etymology

The terms Beck’s Triad are named after Claude Beck (1894-1971) who first described the concept of this medical triad in 1935. Claude Beck was an American cardiothoracic surgeon and Professor of Cardiovascular Surgery at Case Western Reserve University in Cleveland, Ohio.

What is Cardiac Tamponade?

According to DailyMedEd.com, Cardiac tamponade is a medical emergency that refers to a fluid accumulation around the heart. The collection of this fluid exerts pressure on the heart and decreases the ability of the heart to pump appropriately. As a consequence, there is a collection of three medical signs associated with acute cardiac tamponade, known as Beck’s Triad.

The double-layered pericardium surrounds the heart by the formation of a pericardial sac (filled with about 25 to 50 ml of fluid). The fluid essentially acts as a cushion and allows the heart to contract and expand in a smooth fashion by minimizing friction. When excess fluid fills the pericardial space, the pericardium is unable to stretch or expand to accommodate the increase in fluid.

If that pressure from the fluid becomes more than the pressure in the heart’s chambers, the heart will begin to compress and lose its natural ability to pump blood to the lungs and circulate blood to the rest of the body.

The signs of acute cardiac tamponade are hypotension, distended neck veins, and muffled heart sounds. The patient will also be complaining of dyspnea and chest pain along with the following signs:

  • PE will show muffled heart sounds, JVD and hypotension (Beck’s triad), pulsus paradoxus
  • ECG will show low voltage QRS, electrical alterans
  • Echocardiography will show the diastolic collapse of RV

Some other symptoms of tamponade that can accompany Beck’s Triad are:

  • Tachycardia or a rapid heart rate
  • Cold and clammy extremities
  • Anxiousness and restlessness



Pathophysiology of Beck’s Triad

becks-pathophysiology

 How cardiac tamponade leads to hypotension?

Physiological fall in arterial blood pressure occurs because the heart is hindered in its ability to pump blood. When the heart cannot contract efficiently, the rest of the body does not get supplied with the necessary amount of blood. This can result in the body going into shock and even cardiac arrest.

In short, the inability of the ventricles to contract properly reduces cardiac output resulting in hypotension.

Why does tamponade cause distended jugular veins?

The diastolic filling decreases because of the exerted on the right ventricle. As a result, blood flows back into the right atria and the veins that return blood to the heart, most notably the jugular veins.

In a patient with cardiac tamponade, the rising central venous pressure (jugular vein distension) will be present even when they are sitting upright.

In short, the distention of jugular veins occurs due to the back up of fluid into the jugular veins draining into the heart.

How tamponade leads to distant or decreased cardiac sound?

Muffled heart sounds occur due to the insulating effect of the fluid in the pericardial sac. When sound travels through fluid, it sounds distant or suppressed as it is traveling through a thicker median.

In short, the decreased heart sound occurs because of the muffling effects of the fluid surrounding the heart (pericardium).

The full triad of Beck’s is present only in a minority of cases of acute and chronic tamponade. But if present, the cardiac tamponade triad signals the pathognomonic condition of cardiac tamponade.

Beck’s Triad Mnemonic Cardiac tamponade triad mnemonics

3 D’s

» Distant Heart Sounds

» Distended Jugular Veins

» Decreased Arterial Pressure (Hypotension)

beck's-triad-mnemonic-cardiac-tamponade


Beck’s Cognitive Triad for Depression

Some people might get confused about Beck’s Triad for Beck’s Cognitive triad of Depression. But it is a completely different condition that is associated with psychology and psychiatry. Also known as a negative triad, Beck’s cognitive triad is a cognitive-therapeutic view of the three key elements of a person’s belief system present in depression.

It was proposed by Aaron Beck in 1976. The triad forms part of his cognitive theory of depression and the concept is used as part of Cognitive Behavioral Therapy (CBT), particularly in Beck’s “Treatment of Negative Automatic Thoughts” (TNAT) approach.

Treatment of Cardiac Tamponade with Beck’s Triad

As it is a medical emergency, a patient with a cardiac tamponade triad needs immediate hospitalization. There is no any intervention you can do pre-hospital for the patient. The doctor will treat the patient to relieve pressure on your heart and then treat the underlying condition. Initial treatment involves your doctor making sure you’re stabilized.

Your doctor will use a needle to drain the fluid from your pericardial sac. This procedure is called pericardiocentesis. Your doctor may perform a more invasive procedure called a thoracotomy to drain blood or remove blood clots if you have a penetrating wound. There might be a condition to remove part of your pericardium to help relieve pressure on your heart.

Let’s summarize Cushing triad in ICP and Beck’s triad in cardiac tamponade with the following questions:

Question 1 

Which of the given options best describes Beck’s Triad?

Answer Choices

  • Hypertension, JVD, muffled heart sounds
  • Hypotension, JVD, muffled heart sounds
  • Hypertension, bradycardia, irregular breathing
  • Fever, Pain, Jaundice

Explanation

The Correct Answer is B – Hypotension, JVD, and muffled heart sounds.

Answer A – is incorrect. Cardiac Tamponade Triad includes hypotension, not hypertension.

Answer C – is incorrect. It describes Cushing’s Triad in pt. with increased intracranial pressure in cases such as traumatic intracranial hemorrhage from trauma.

Answer D – is incorrect. It describes Charcot’s Triad in pt. with ascending cholangitis

Question 2

Which of the given options best describes Cushing Triad?

Answer Choices

  • Hypertension, JVD, muffled heart sounds
  • Hypotension, JVD, muffled heart sounds
  • Hypertension, bradycardia, irregular breathing
  • Fever, Pain, Jaundice

Explanation

The Correct Answer is C – Hypertension, bradycardia, irregular breathing

Answer A – is incorrect. Cushing’s triad includes hypertension, bradycardia, irregular breathing

Answer B – is incorrect. It describes Beck’s Triad in pt. with cardiac tamponade.

Answer D – is incorrect. It describes Charcot’s Triad in pt. with ascending cholangitis


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