Of blown pupils and brain waves

Antikigirl, ASN, RN · Nov 3, 2004

WOW! Okay I think your friend needs a physician that is truthful and explains things honestly and to the point. Or gee...here is an idea...a nurse to do it as well, since it is our responsiblity to ensure we help the family as much as possible cope with this (kind of the whole family dynamic deal).

Blown pupils...not good. Vent...not sure, I don't deal with vents, haven't had the experience (more emergency and then long term care here). But I stick with simplicity...blow pupils, not good! (sometimes being simplistic helps take things down to a level of understanding for everyone...then work up from there).

Poor friend! Hope for the best in that situation, whatever that may be (I work long term, I tend to think vent, quality of life after if after is possible...blown pupils, massive MI, damage...ummmmmm time to think of quality not quantity).

UM Review RN, ASN, RN · Nov 3, 2004

I'm not sure if his pupils are blown, I'm inferring that because how else would they assume no brain activity without an EEG?

Please keep this family in your prayers. The poor patient is only in his 50s.

RN4NICU, LPN, LVN · Nov 3, 2004

I'm not sure if his pupils are blown, I'm inferring that because how else would they assume no brain activity without an EEG?
Please keep this family in your prayers. The poor patient is only in his 50s.

Apnea testing perhaps?

Dinith88 · Nov 3, 2004

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.

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.

Trauma-tizedRN · Nov 3, 2004

Sedated on the vent, pupils should still react even if sluggishly...have they weaned him off to check baseline? blown pupils look pretty obvious too. Any corneal reflexes is good to know. Needs to request an EEG and/or ice calorics....and a complete explanation from MD. my 2 cents.

UM Review RN, ASN, RN · Nov 3, 2004

Thanks for your answers. As I said, my info is pretty sketchy at this point, and I'm only guessing why the neuro doc would say that without an EEG, which my friend insists was not done.

And this is a new one on me--they couldn't do a CT scan. He's a large man and she was told he couldn't fit into the machine. For a head CT? What's that all about?

Elenaster · Nov 3, 2004

CT scans are utilized to evaluate for the presence of a stroke or hydrocephalus in a patient with a suspected neurologic injury. It sounds to me like your friend's dad has an anoxic brain injury from the MI and I doubt a CT would reveal much information.

To the best of my knowledge, you cannot evaluate for brain wave activity without an EEG. If brain death is suspected, the docs can perform a number of tests that have already been mentioned here or a nuclear flow study to evaluate blood flow to the brain.

I'm guessing that he has a Glasgow Coma Score of 3 without heavy sedation and that's why there's such a grim report. Do you have any clue what they're sedating him with? Unless they're using NMBAs or have induced a barbituate coma (which is rare), most sedatives can be turned off and brain death testing can be performed within a couple of hours.

UM Review RN, ASN, RN · Nov 3, 2004

CT scans are utilized to evaluate for the presence of a stroke or hydrocephalus in a patient with a suspected neurologic injury.

I was only wondering why he "couldn't fit" in the machine. I work on a Progressive Care unit and I've never heard of a patient not fitting into the CT scan before. OK, maybe for a CT angio of the chest, but not the head.

Do you have any clue what they're sedating him with?

No, my friend would have no idea about that and I don't want to overwhelm her with all that information and quizzing. The ICU is an area I have no working knowledge of at all. I only know that patients on vents are sedated. We've had to bag and intubate a couple of patients on my unit in emergencies, and I assisted with that before the (really fast!) transfer to ICU, but that's as far as my clinical experience goes.

Thanks for the information though, it's helping me sort out what might've happened. So far the prognosis doesn't look so great, and that's better than not knowing anything.

CC NRSE · Nov 3, 2004

the answer to your question about your friends father won't "fit", most ct tables will only accomodate a patient weight of 400lbs.

the other issues,..if his pupils are blown, no cough, no corneal or gag reflex,....chances are he was down to long and suffered an anoxic injury which he will not recover from. there probable was no eeg preformed because these are pretty definate signs knowing the history. i have seen this many times and can't recall seeing anyone recover. (although that doesn't mean this is the case with your friend's dad.) your friend could insist on an eeg just for her own knowlege and sanity. i don't think that would be out of the question. she just needs to understand even if he is not clinically brain dead (no wave activity) he may never recover any more than what she sees now d/t the injury already substained.

also keep in mind,...your friends dad may not be sedated with anything. if he is not responsive, then there is no need. sedation would not indicate the pupils being blown. when did this happen?

i am very sorry this happened. it is always a difficult situation.

UM Review RN, ASN, RN · Nov 3, 2004

Thanks for your response. I think I keep asking because I know deep down....I know. *sigh* These situations are always difficult, the more so if it's so close to home.

Best thing for me to do now is turn off the "nurse" and be the "friend" for her. :crying2:

delta32 · Nov 4, 2004

Thanks for your answers. As I said, my info is pretty sketchy at this point, and I'm only guessing why the neuro doc would say that without an EEG, which my friend insists was not done.
And this is a new one on me--they couldn't do a CT scan. He's a large man and she was told he couldn't fit into the machine. For a head CT? What's that all about?

Another good indicator that there is a problem is when diprivan or what ever sign of sedation that the patient may be on is turn off and no movement or breathing over the vent is noted. they may as well if he is comatose with out fighting the vent have him off sedation. But i do not see any doctor telling someone's family this information with out knowing that the patient is brain dead.