causes for a non reactive pupil

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Specializes in ER.

A woman came into our ER with 2 hours confusion and repeating illogical behavior, like rubbing the top of a countertop over and over again and saying "I need to turn it on." She was 55 years old, on a fair number of meds including Vicodin for back pain that her husband said she didn't take very often, but her didn't know when the last dose was. GCS 14, able to answer simple questions with 1-2 words, but falling asleep. No unilateral weakness or sagging, but on one of my many assessments I found a nonreactive left pupil. All other vital signs were in the normal range. With Narcan she was able to stay awake, but still had illogical behavior and appeared sedated. She also had a UTI, all other labs except tox screen (she had her regular meds in her system) were normal.

Dx was overdose with infection, but no head CT was done. We had her for about 3 hours, and she was still trying to put the johnny as a coat when she left, although she could walk she needed cueing as to where she wanted to go. On discharge her pupils were equal and reactive, but should I have pushed more for a head CT based on the assessment? Would the diagnosis have caused a transitory nonreactive pupil with no other change in assessment at that moment?

This case doesn't mesh for me and I am concerned about her.

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Specializes in Emergency.

Sounds like malpractice to have not done a head CT on a person with altered mental status. I have seen them done on patients with less. Also from the description I might have scored their GCS lower, but having not been there thats hard to do.

Rj

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Specializes in Utilization Management.

Would've definitely rated a CT head in my facility, maybe even an overnight stay with a neuro consult for possible TIA due to AMS.

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Specializes in ED-CEN/PACU/Flight.

It would have received a CT scan at my facility as well. I'm surprised the MD didn't order one.

You can only do what you can do - and it's obvious you are very concerned and care greatly for your patients.

Let us know if you hear anything.

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For sure a head CT was in order as well as an admit at least to an OBV bed, with eval by a neurologist.

I've never seen a minor narcotic OD result in one non reactive pupil.

You were right to be concerned, but you can only do so much. Can you do a follow up call to see how she is?

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Specializes in Cardiac, Acute/Subacute Rehab.

This may be something I learn along the way in my studies, but. . .what would actually cause a pupil to become nonreactive on only one side?

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You mean she was discharged HOME while still disoriented somewhat and needed help finding her way around? And this was a previously functional women with no hx of dementia? That is certainly malpractice. I don't think it's your fault, but maybe the ER doc likes court or has really good insurance. :uhoh21:

I don't work ER but can you refuse to discharge someone?

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Wow, I'm very suprised a ct head was not done. She could have had a bleed causing her to be like that. Neuro would have been on the case in the facitlity that I work at.

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My immediate thought would have been a subdural.. I'm very surprised they didn't do a CT and instead just went on a whim!

I hope the lady was ok in the end.

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Specializes in E/R, Med/Surg, PCU, Mom-Baby, ICU, more.

IMHO a CT should have been done. I would be thinking of a slower process rather then a cerebral bleed as a severe headache goes along with a bleed 90% of the time and pupil changes are a late sign with ICP due to a bleed. I'd be thinking of lesions some place. Very weird that her pupils were at WNL at discharge. Hopefully she is OK.

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glass eye?

kidding

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Specializes in ER, Peds, Charge RN.

Narcs could mess with the pupils, but I wouldn't think it would bother one without the other. I've had two cases of a non-reactive pupil. One guy ended up with a small pituitary adenoma, and the other was a little guy (12) who had some junk fall on his head. He had a temporal lobe linear fx. His was interesting, because it was only for a little while, and then returned to normal. It wasn't due to bleeding or any of that. I asked my neuro doc about it, and she said that sometimes it is a reaction to head trauma, and it doesn't necessarily signify increased ICP. In this case, it will go back to WNL, and they aren't sure exactly why. I'm flipping out over this guys pupil, and it ended up being nothing.

Maybe it could be way out of the box and have something to do with oculomotor nerve malfunction?

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