Assessing Pupils

alarm_on09-May-2022

Hello welcome to another EMS webcast. This webcast is going to be all about assessing pupils and how we can use the pupils to help us get the pieces that we need to solve the puzzle and what's going on with our patient. So let's, just go ahead and dive right into it.

Let's. Take a look at the optic nerve here. And you can see that it's know, pretty proximity to the brain. So the pupil is a perfect way to monitor what's going on with the brain, a lot of clues.

You can see you're just by the. Straight-Up anatomy and physiology, how that would work? So what do we know is normal before we can know what's abnormal.

And when we assess pupils as an EMT, we use the acronym pearl, which is a normal finding, and it stands for pupils are equal and round and reactive to light as you can see here, this person's being assessed, and we have a penlight, and we essentially shine it in one eye. And we look at the opposite eye for people constriction. And then we go to the other eye shine it in their eye.

And. Look for people constriction on the opposite eye, and then prior to people constriction, we try and make a determination of what the diameter of their pupil is as you'll see further here in this webcast, how that makes a difference and why we need to know that let's take a look here. And this is how essentially what a pupil assessment looks like. This is the pupillary response. Give you a lot of information. We can tell you about patient's neurological status as well as a potential drugs that are first. Assess the diameter of the people here it's about six millimeters, you see light flashing it into the pupils and looking for to constrict also note when I flashed into one eye, both eyes will constrict and that's assessment of pupillary reaction.

What we have on this graphic are the sympathetic and parasympathetic neural pathways. If you recall from basic anatomy and physiology, sympathetic is your fight-or-flight response, prepares your body for fight or a runaway so different responses on each. Of the organs and different parts and regions of the body actually work towards it.

So your eye and your pupillary response on sympathetic pupils get big. They dilate let more light in along with other things. Your heart rate increases your lungs kind of open up all right and I, don't know.

So sympathetic stimulation pupils, dilate, parasympathetic stimulation. Pupils, constrict, remember, your parasympathetic is rest and relax as you sleep at night, or you're, relaxing, your pupils constrict to let that. Slide in just sorta Lao you to relax, go to sleep rejuvenate, so I like this graphic, because it reminds me not only with the pupil response we have if you have a people response, that's, very large because dilated, you have sympathetic neural stimulation going on may see other things, or you may not drug can cause that act on these pathways. So sympathetic drugs are called some paths on emetics. So in other words, drugs that stimulate this nervous system and cause these responses, elicit type drugs, I.

Could do this one will be that's used that's common these days, methamphetamine because people's to keep big, they can cause a heart rate to increase and all these other responses act on drugs that act on the parasympathetic division illicit drugs, heroin will cause people's to constrict. And as you relax, your heart rate slows down your respiratory rate decreases the artificial response from Erin can actually cause your respiratory system to cease completely. So pupils are excellent vital sign. And. Remember from this graphic now there are other parts of the body that may being affected too so make sure you get a complete set of vital signs, dilated pupils, let's talk about what can cause dilated pupils.

So pupils that are pretty wide as we see here in this graphic, they could be indication of a couple of things. First it just could be natural could be that your patient is agitated or in a panic state. Okay, if your patient is agitated or a panic state that should be pretty obvious. And when you go to check pupils, the pupils are going to constrict as they normally would, however, pupils are dilated. One of the things I like about checking pupils for seizure. Responses are it lets? You know if your patients still having a seizure.

So when people have seizures, they have that tonic-clonic activity, they have that they have the actual active state of a seizure. And then it's followed by a period of what's called a postictal state, where in other words over the body sort of recovering, but. They're still seizing, they are not back their normal mental response.

So typically after a seizure in that postictal state in EMS, we get called out patient as having a seizure. We get out their patients, don't conscious we're, trying we're trying to establish a level of consciousness. The first thing I do is I check pupils with my light. And if you, if you see pupils like this in a postictal state seizure, and they are not constricting with the light or the patient's still in that postictal. State there, you're going to be completely unresponsive.

But as soon as you have people start to constrict, well, their mental status is returning normal level. Consciousness is returned to normal and that's when you can sort of wake them up. And you can also be cautious, because as you know, patients coming out of postictal, sneaking me confuse can be agitated a number of things, but pupils are an excellent vital sign indicator seizure states. It could also be the patients and under the influence of.

Speed type drugs, methamphetamine, sympathomimetic, s--, right working on that sympathetic neural pathway. It could be also a potential chemical poisoning. It could be at injury and then don't, forget.

They the stuff that you could easily overlook about the page. You could just simply have a glass side. So with pupils, great, great, exceptional tool for EMS, but there's your science as I've said, several times in my lectures, all your signs and symptoms and questions are all just pieces of a puzzle. You. Need to look at the whole picture.

What I like about this video is its law enforcement video. And it looks like we have an actual patient now note, how big the patient's pupils are. And when they officer shine the pen light and the patient's eyes, they should have constricted, and they're, very, very slow to constrict. So again, you can't just because the patient's pupils are dilated. You can't just right away jump to the conclusion that they're on some sort of drugs again with medicine.

There are signs. Symptoms history gathering these are all just pieces that we put together to complete the puzzle to give us the best to give us a best guessed so to speak. We technically we don't diagnose in the field, but it gives us our best guess as to what's going on with the patient let's go the other way and talk about constricted pupils, okay, that's, actually a typo that should be the parasympathetic nervous system as being stimulated.

So that would be your rest and response could be your patient. Sleeping could be a patient's under the influence of narcotics. Now in narcotics, classical signs would be, these would be definitely pinpoint pupils. So we call them pinpoint.

Because if you look at the size of the pupil it's about the size of a head of a pen, so the people's pupils do not get that small naturally case, pinpoint pupils combined with depressed. Respirations is a classical sign of a narcotic overdose and dependent upon the protocols. You could be allowed to administer narc an, probably as. Ems progresses narc an will be in the scope of practice for EMT. Basics. Paramedics can give it.

They've always been able to give it. But now they're actually making the administration of narc an more accessible, all nightie basics, but actually they're available to us. They actually teach patients. You know, what with this addiction of the deflection that's, how to use them. So narc an, you're going to see more narc an more widely available use of narc an.

Another thing that could be happening is actually a. Pesticide, or even a nerve agent nerve agents and pesticides react on the nervous system, actually cause pinpoint pupils and breathing problems. You suspect any one of these circumstances, you're definitely may not being an unsafe scene. You could have a contaminated patient.

Furthermore, you want to make sure you're seeing safe, and you're, not going to be exposed to that pesticide or nerve agent as well. Let's. Take a look at this video here for a second and pay attention to the respirations and the pupil. This is a.YouTube video of parent, actually experiencing an overdose, don't do it like that all right get up get up get up. Hey, thanks mug.

Jeff I think, hey, look anybody there so in that previous video, her pupils weren't quite pinpoint, but they were getting there. It slowed things we look for what else could that peoples tell us? Well, if they are unequal that is actually a classical sign of a head injury with increasing intracranial pressure, what's happening is there's pressure, building up I'm. The.

Affected side causing the other eye. So in this case, this looks just how this snapshot of this patient looks I. Would this look like possible drug use to me? Because the skins don't really look cool. She doesn't look distressed her tea, I'm, not sure, okay.

But what this pupil here if this was patient, if I saw this patient, looking like this after a car accident with a decreased mental status, I would definitely suspect that the patient has a head injury and there's pressure building up on the. Opposite side of the brain interfering with that optic nerve, very important findings that you need to relate to the hospital. And again, don't make the rookie mistake of a glass eye fixed, midpoint pupils. And this graphic you can see when we midpoint is there, neither constricted nor dilated they're right in the center. Now, if you have these on both eyes patients, not breathing, that is a sign of extended death to the point where patient is non-salvageable in other words, CPR and AD isn't that it's, not. Is it appropriate to use Tech's, midpoint pupils, extended sign of death. They do have no sympathetic expansion or person to the constriction in the brain it's brain, death.

Okay, things, doesn't know. Now we get to one of my actual favorite things that I've learned Russian, paramedic school missed Agnes. What is nystagmus?

Well, nystagmus is basically as your eyes track left to right. It should be a smooth type movement. Right if they start to stutter or skip you have a basically a sign on your. Hands so what it could, it cause that? Well, certain types of brain diseases or injuries could cause it corneal disorders actual disorders of the eyes. But the one you're probably most familiar with is what the law enforcement uses for field, sobriety checks to check if you see is you our suspect to be under the influence of alcohol. Okay.

So what the officer do is hold a pencil or stick in front of your face, instruct you to look straight ahead to not move your head and just follow with your eyes. And what. They're looking for as you as your eyes track back and forth, they don't skip what tends to happen as blood-alcohol level starts to increase is at the very lateral corners of your eyes, they're going to start to skip a little, so it's going to be track skip now as blood alcohol concentration starts to increase the skipping becomes more pronounced and moves more towards the center. So that's, what they're looking at also hallucinations can cause nystagmus there's, actually quite a few. Things that can cause nystagmus, but it's, again, pieces of the puzzle say, for example, it's a car accident, there's, beer cans and alcohol bottles. There are patient smells like alcohol.

And you perform this check well, you could probably guess the patient's under the influence of alcohol. Why do we care? I mean, law enforcement, obviously because of laws and violations, but for us, we just want to know exactly what's going on with our patient. So we can treat them appropriately, that's. The only reason we're. Concerned about it let's go to the next slide, and we'll see, actually what it looks like the horizontal gaze nystagmus test is a test that the police officers will do in the field to determine whether someone's been drinking.

Or if they're impaired nystagmus is the involuntary jerking of the eyes, which is naturally present in all people, but is highlighted once alcohol is introduced to their system. What a police officer will do during the horizontal gaze. Nystagmus tests usually ask a. Subject to follow the tip of their pen from left to right all to be watching the individuals eyes if you've been drinking, an officer's doing the horizontal gaze, nystagmus test there's, really no way to kind of trick the tests. So what we just saw was a nystagmus and again, it's pieces of the puzzle.

What I really like about pupils is I, won't, I, don't want to say red flags, but they are good indicators that are help you confirm your findings on your differential diagnosis to figure out what's. Going on with the patient, so I hope, you learned a few things and remember to always add those into your vital signs. So you're, checking blood pressure, pulse, respirations amount of pupils along with your mental status and skin signs check up on all your patients and Stacy. Thank you.

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