Cushing's Reflex

From Episode 181 on the ECC stream. With Dr Leah Wright.

This epic traumatic brain injury recap reminded me to look out for the Cushing’s reflex in patients with bad brain disease. Here’s a recap:

• The Cushing’s Reflex is a last-resort compensatory mechanism triggered by the brain in response to severely increased intracranial pressure.

• You’ll see:

• Progressively increasing blood pressure - the body’s attempt to try to maintain cerebral perfusion. (Higher pressure in the skull requires higher blood pressure to try get blood to the brain.)

• Progressive bradycardia as a secondary response - feedback loops sense a high blood pressure and drops heart rate in response.

Pro tip: Some human studies show that initially, the heart rate may actually increase, but as blood pressure continues to rise, the classic reflex bradycardia develops.

Key Clinical Takeaway:

• If you see high blood pressure + a sudden drop in heart rate in a neuro patient, things are bad.

• This is not a blood pressure problem—it’s a brain problem. Your patient needs hypertonic saline or mannitol like an hour ago.

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