10/16/2026
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Cushing’s triad is a late warning sign that a traumatic brain injury (TBI) has progressed to imminent brainstem herniation. Waiting for these terminal signs to appear before intervening in a Prolonged Field Care (PFC / PCC) scenario means you are already behind the curve.
When an intracranial bleed causes pressure to build inside the rigid walls of the skull, the body triggers three classic physiological responses to maintain cerebral perfusion:
• Widening Pulse Pressure
• Bradycardia
• Irregular Respirations
The Strategy: Treat Early and Aggressively
Evidence from the CRASH-3 trial and Joint Trauma System (JTS) Guidelines proves that your window of opportunity sits entirely in the mild-to-moderate TBI stage. If you wait for Cushing’s triad to manifest, the survival benefit of your interventions drops exponentially because structural failure is already underway.
To stay ahead of intracranial pressure (ICP), PFC protocols dictate immediate, proactive management:
• Aggressive Clot Stabilization: Administer Tranexamic Acid (TXA) as a single 2g slow IV/IO push within the strict 3-hour window from the initial injury. Head trauma triggers hyperfibrinolysis, causing the body to prematurely melt its own clots. As an antifibrinolytic, TXA stabilizes those early clots to halt hematoma expansion.
• Proactive Physiology Management: Optimize cerebral venous drainage immediately by elevating the casualty’s head to 30 degrees and keeping the neck in a neutral alignment. Monitor aggressively to prevent the “deadly dual insults” of secondary brain injury: hypoxemia and hypotension.
• Osmotic Intervention: If signs of herniation or pupillary changes develop during prolonged holding, immediately transition to osmotic therapy by administering 3% Hypertonic Saline to reduce brain swelling.
When evacuation timelines stretch into hours or days, passive observation allows intracranial pressure to take over. Treat the underlying bleed early, control the physiology aggressively, and protect the brain before irreversible damage sets in.
