Of blown pupils and brain waves

[UM Review RN]

A friend across the country called me the other day and her dad apparently had a massive MI. He called out, she found him on the floor. He was subsequently Coded, given bicarb (sounds like it might've been a long Code).

He's in ICU and on a vent.

She said that the neuro doc says that her dad has no brain wave activity. She insists no EEG has been done, and that she's sure because someone's been by his side since the incident.

So I'm guessing that the neuro doc is seeing blown pupils.

My question is--if someone is heavily sedated from being on a vent, do their pupils react normally? Have you ever seen a change in that status?

I don't want my friend to hope for results that cannot be realistically achieved. I met her dad a couple of times and really liked him. He'd want nothing less than the truth.

[UM Review RN, ASN, RN]

Update: she called me last night and insists that he's responding ever-so-slightly to touch and to hearing his children's names.

She also told me that they haven't done an EEG and will do one today. And that he's been on paralytics and sedatives.

So....I guess he might still be in there kicking.

She also said that he arrested while the paramedics were there and thus was treated immediately, so no real down time.

I'm starting to have a niggle of hope. :)

[UM Review RN, ASN, RN]

Just wanted to say thanks to all of you for your responses.

He passed away this morning.

[NotReady4PrimeTime, RN]

Angie, your friend has our sympathy. She's lucky to have you for a friend. I'm sure your support has been very important to her.

[veteranRN]

Best wishes being sent your way as you remove your nurses cap and become just a friend. She's lucky to have a friend like you.

[CC NRSE]

angie,

i am so sorry.......... your friend truely is lucky to have you.

[UM Review RN, ASN, RN]

Thank you all, I'm just so glad that she and her family got to say goodbye.

He was too young, true, but at least he didn't linger in pain, and she's taking comfort in that as well.

[Shed13911]

Prayers offered here from all of us. The loss of a parent is always hard but even more so when they were young when they pass. I am so glad they had the time to say goodbye and let him know how much he was loved.

[NeuroICURN]

Either A) The neurologist DID an EEG...or

B) The neurologist is making a statement he shouldnt make (regardless of his probably being correct).

Or...your friend just has her information a bit messed up..

Yes..blown pupils are bad and mean brain-death...but you're making an assumption here. Even if the neuro did see blown pupils, an eeg is in order and would be preformed to make the Dx of brain-death official.

And no, sedation given to ventilated patients wont blow pupils..and if the nurse notices blown pupils in a sedated pt that previoulsy were reactive, big problems have occured and a head ct would be done asap(and hyperventilation, etc.). If a pt has pupillary changes from sedation it would more likely be tight/constricted pupils...but they should still react.

As a neuro nurse, I have a real problem with some of the statements made in your posting.

Blown pupils can mean brain death, but don't always.....so, please don't ever make a statement like that again. There's WAY MORE to brain death criteria than just blown pupils. Also, an EEG is not always part of the criteria, but it can be one of the tests done.

Ok, yes you were correct with the head CT being done for any neurological changes noted. However, we don't hyperventilate anymore....this is only a very short term fix, but usually causes MORE of a problem later. Anyway, as for the CT....without getting into great detail here, it can tell you some things, but not others. It can identify if he has any bleeding, perhaps from the fall, it can show a stroke from a clot....but it takes 2-3 days for that to show up. A CTA can be done to visualize the vasculature.

As for sedation for a vented pt., propofol (Diprivan) is the most commonly used one. Propofol tends to make pupils pinpoint and difficult to assess. Thankfully though, it only has a half-life of approx. five to ten minutes, so assessment can be done pretty quickly. But yes, if someone has a blown pupil even while sedated on propofol, then there is a problem.

The best advice I can give to you is to tell your friend that she needs to sit and have an honest, frank discussion with the neurologist. Also, I like what the OP said about just being a friend now. I'll keep everyone in my thoughts.

Edit: Sorry, this was posted before I finished reading the second page's postings. I'm sorry to hear that your friend's dad lost his battle, but I hope that he has found peace. Again, I'll keep you all in my thoughts and prayers.

[UM Review RN, ASN, RN]

Thanks for the information, NeuroICURN. My unit doesn't use vents or propofol, which is why I was clueless in this case.

Nevertheless, your information is helpful to me because we are a stroke unit, and who knows? I find that information that I get here comes in handy at some point.

The family is having a simple memorial service today, which is what he would've wanted.

Again, thanks for all of your thoughts and prayers to this family in their time of loss.

[gwenith, BSN, RN]

With anoxic brain injury there are a couple of non-neurologic findings that if present make EEG's and brain death tests moot. One is "Box cars" on the retina - areas of small anoxic injury - these are almost invariably mirrored on the brain and indicated global ischaemia.

The other is the diarrhoea - that is distinctive. It come from ischaemic gut. Obviously if the gut has signs of ischaemia then the brain which requires a higher oxygen demand will have suffered more.

Sometimes the brain death tests are not done straight away because intially the patient will not fit the criteria but as time goes on and the areas of the brain that suffered ischaemia swell then with the rising ICP there is more damage until death ensures.

Sorry for your freinds Dad.

[Dinith88]

As a neuro nurse, I have a real problem with some of the statements made in your posting.

Blown pupils can mean brain death, but don't always.....so, please don't ever make a statement like that again. There's WAY MORE to brain death criteria than just blown pupils. Also, an EEG is not always part of the criteria, but it can be one of the tests done.

Ok, yes you were correct with the head CT being done for any neurological changes noted. However, we don't hyperventilate anymore....this is only a very short term fix, but usually causes MORE of a problem later. Anyway, as for the CT....without getting into great detail here, it can tell you some things, but not others. It can identify if he has any bleeding, perhaps from the fall, it can show a stroke from a clot....but it takes 2-3 days for that to show up. A CTA can be done to visualize the vasculature.

As for sedation for a vented pt., propofol (Diprivan) is the most commonly used one. Propofol tends to make pupils pinpoint and difficult to assess. Thankfully though, it only has a half-life of approx. five to ten minutes, so assessment can be done pretty quickly. But yes, if someone has a blown pupil even while sedated on propofol, then there is a problem.

.

Other than hyperventilation being old fashioned, however, you didnt really say anything new. And what less ominous condition can blown pupils indicate? (before you answer, i mean bilateral fixed and dilated pupils.)

[gwenith, BSN, RN]

I have seen blown pupils in dilantin (Phenytoin) overdose and the patient recovered!!!! The only time (almost) I have seen fixed dilated pupils that subsequently walked out the door.

It can also simply signify a III nerve lesion.