EMS Medical Terminology - Cushing's Disease

EMS providers should have a  understanding of Cushing's Disease and its potential implications for prehospital care. 

Cushing's Disease is a condition caused by prolonged exposure to high levels of cortisol, often due to a tumor in the pituitary gland that leads to excessive secretion of adrenocorticotropic hormone (ACTH). This, in turn, stimulates the adrenal glands to produce excess cortisol.

In terms of prehospital care, EMS providers should be aware of the signs and symptoms of Cushing's disease, which may include:

Hypertension: High blood pressure is a common feature of Cushing's disease due to the effects of excess cortisol on blood vessel function.

Weight Gain and Obesity: Patients may exhibit central obesity, particularly in the abdomen, along with increased fat deposits in the face (moon face) and neck (buffalo hump).

Muscle Weakness & Wasting: Excess cortisol can lead to muscle weakness and atrophy, which may affect the patient's mobility and ability to cooperate during assessment and treatment.

Skin Changes: Patients with Cushing's disease may have thin, fragile skin that bruises easily. They may also develop stretch marks (striae) on the abdomen, thighs, and breasts.

Glucose intolerance & Diabetes: High cortisol levels can impair glucose metabolism, leading to insulin resistance and, ultimately, diabetes mellitus.

Psychological Symptoms: Patients may experience mood swings, irritability, depression, or cognitive disturbances due to the effects of excess cortisol on the brain.

In terms of potential issues for prehospital care, EMS providers should consider the following:

Cardiovascular Complications: Patients with Cushing's disease may be at increased risk of cardiovascular events such as heart failure, myocardial infarction, or stroke due to hypertension and other metabolic disturbances.

Fluid & Electrolyte Imbalances: Excess cortisol can disrupt fluid and electrolyte balance, leading to conditions such as hypokalemia (low potassium levels) or hypernatremia (high sodium levels).

Adrenal Crisis: In some cases, abrupt withdrawal of cortisol due to treatment or other factors can precipitate an adrenal crisis characterized by hypotension, dehydration, and shock. EMS providers should be prepared to recognize and manage adrenal crisis promptly.

Communication Challenges: Patients with Cushing's disease may have physical or cognitive impairments that affect their ability to communicate effectively. EMS providers should employ clear communication techniques and be patient and empathetic when interacting with these patients.

Who Made The Dicovery?

The discovery of Cushing's disease is credited to Dr. Harvey Cushing, an American neurosurgeon. Dr. Cushing first described the condition in 1912 in a detailed report titled "The Pituitary Body and its Disorders: Clinical States Produced by Disorders of the Hypophysis Cerebri." 

In this seminal work, he provided comprehensive observations of patients with pituitary tumors, including those exhibiting symptoms of hypercortisolism, now recognized as Cushing's disease. 

Dr. Cushing's pioneering research laid the foundation for understanding and diagnosing this disorder, and he is regarded as a key figure in the history of endocrinology and neurosurgery. This is an example of an eponymous medical term.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice Volume 1 (6th Ed) Pearson.  

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Medical Terminology - Cushing's Triad

Cushing's Triad is named after Dr. Harvey Cushing, an American neurosurgeon who made significant contributions to the field of neurosurgery. This is an example of eponymous medical terminology.

Dr. Cushing described a set of clinical signs and symptoms associated with increased intracranial pressure in his work "Intracranial Tumours: Notes upon a Series of Two Thousand Verified Cases with Surgical Mortality Percentages Pertaining Thereto." 

This work was published in 1901, and it was one of the earliest descriptions of the physiological changes associated with intracranial pressure.

Recognizing Cushing's Triad is crucial for EMS Providers, as it is suggestive of a potentially life-threatening situation due to various adverse conditions, including head injuries and brain pathologies. 

As such, the need for urgent medical intervention is paramount.

Cushing's Triad consists of the following three key signs:

Hypertension (High Blood Pressure):

A significant increase in systolic blood pressure is a common feature of Cushing's Triad. This is a response to the body's attempt to maintain cerebral perfusion (blood flow to the brain) in the face of elevated intracranial pressure.

Bradycardia (Slow Heart Rate):

Cushing's Triad often includes a slow heart rate (bradycardia), particularly as a result of increased ICP. This is a compensatory mechanism intended to decrease the heart's pumping strength, reducing blood flow to the brain and thereby minimizing the risk of further brain damage.

Irregular or Abnormal Respiratory Patterns:

The third component of Cushing's Triad is abnormal breathing patterns, typically characterized by irregular or irregularly deep respirations. This is often referred to as "agonal" or "Cheyne-Stokes" breathing.

These respiratory changes are a response to the brain's attempt to restore oxygen levels and eliminate excess carbon dioxide, which can occur due to impaired blood flow or brainstem compression.

Recognizing Cushing's Triad in a patient is a critical finding for EMS providers, as it may indicate an impending brain herniation, which is a life-threatening condition. 

Patients displaying Cushing's Triad should be managed promptly and transported to a specialized facility for further evaluation and potential surgical intervention.

Here are some key points for EMS Providers:

- Perform a detailed neurological assessment, including monitoring vital signs, level of consciousness, and pupillary response.

- Administer supplemental oxygen to ensure adequate oxygenation.

- Maintain cervical spine immobilization to prevent further spinal cord injury, if applicable.

- Communicate with the receiving medical facility to ensure they are prepared for the patient's arrival and can provide neurosurgical expertise if necessary.

- Avoid hyperventilation, as it may worsen cerebral ischemia.

- Cushing's Triad is a critical clinical finding that requires immediate attention and transport to a higher level of care. 

- EMS providers should follow their local protocols and seek medical direction when managing patients with Cushing's Triad.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Ebright, C. (2024) Unique Patient Signs: A Case Study. EMS1. https://www.ems1.com/patient-assessment/articles/unique-patient-signs-a-case-study-f4CQBuoUo9uTCHrZ/ Accessed May 1, 2024

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell