# When To Check PEARL



## pirate000 (Apr 12, 2010)

As an EMT-I, when is a practical / appropriate scenerio for checking pt eyes for PEARL?


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## JPINFV (Apr 12, 2010)

> When to check PEARL



Any time you do a physical exam, especially anytime you think the patient might be neurologically impaired (whether through primary disease such as a stroke, or secondary to a disease such as an overdose, underdose, or trauma).


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## emt_irl (Apr 12, 2010)

its non invasive so technicially anytime to every patient.

for example: i wouldnt do it to a kid who stubbed there little finger in the garden. but i would if a guy has just come out of a kick-boxing match with a sore leg.(just to clarify the last point, there may be more trauma then a sore leg eg head injury)


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## EMSLaw (Apr 12, 2010)

It's part of your basic physical exam, so I would venture to say that you should do it on every patient. It's not as if you can't spare the ten seconds.  "Look at me, please.  Alright, I'm going to shine this light in your eyes, it's not going to hurt..."  One, two, done.  

I'm sure milage varies on this, but since it's "Pupils Equal and Reactive to Light" or "Pupils Equal, Round, and Reactive to Light", I learned it as PERL or PERRL.  Not a big issue. As to the second initialism, I'm not sure how pupils manage to be unround, absent some sort of weird trauma or cats-eye contact lenses.


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## TransportJockey (Apr 12, 2010)

There's allso PERLA (Pupils Equal and Reactive to Light and Acomidating)


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## bstone (Apr 12, 2010)

Always check PEARRL.


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## EMSLaw (Apr 12, 2010)

jtpaintball70 said:


> There's allso PERLA (Pupils Equal and Reactive to Light and Acomidating)



What does accommodating mean in this context?  Never heard that one.


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## TransportJockey (Apr 12, 2010)

EMSLaw said:


> What does accommodating mean in this context?  Never heard that one.



From what I was told, have them look at a finger held directly in front of one eye (or a light), the other pupil should have an opposite response to the pupil you are testing. I hope that makes sense.


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## LondonMedic (Apr 12, 2010)

PERL should be done with any 'D' assessment. If you feel the need to assess someone for neurology, be it AVPU, GCS or a full neuro exam, you should probably check pupils.

However, common sense dictates that you should only do a test when you know what to do with the answer...





EMSLaw said:


> What does accommodating mean in this context?  Never heard that one.


You should be able to see the eyes converge as they focus on near objects and diverge as they look further away.


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## JPINFV (Apr 12, 2010)

Accommodation is the ability of the eyes to focus on near objects. 3 separate things happen during accommodation. The eyes converge  (there is a "convergence" center that controls specifically this), the pupils constrict, and the lens bulges (ciliary muscles contract. Actually, this part works opposite of how you think it happens a priori, but I digress) to focus light on the fovia. To be honest, if you are checking accommodation, you should probably be checking the rest of the extra ocular motors with an "H-test" ("Follow my finger with just your eyes" and trace an "H" in the air in front of the patient). If you are just shining a light into the patient's eyes, then you aren't checking for accommodation.


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## emt_irl (Apr 12, 2010)

jtpaintball70 said:


> From what I was told, have them look at a finger held directly in front of one eye (or a light), the other pupil should have an opposite response to the pupil you are testing. I hope that makes sense.



yeah it does and its correct from my experence


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## mcdonl (Apr 13, 2010)

*Good site on Dilated Pupils.*

As part of my NREMT-B study process I am taking practice tests. From the advice of the ones on here who know, I am focusing on understanding why an answer is correct, not just that I pick the right one. 

So when I think I know the answer but I am not sure why... or I am not sure of the correct answer I do research... one of the questions yesterday was about what symptoms could lead to non-reactive pupils so I went searching for more information and came up with this site:

http://www.wrongdiagnosis.com/symptoms/dilated_pupils/common.htm

It had a lot of stuff on there that was way beyond the scope of what I needed or frankly what I could comprehend with my limited knowledge of anatomy, but it did teach me a better understanding of why we do the test, when to do the tests and what the problems may be.

Leroy


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## EMT_TIFFANY (Apr 13, 2010)

I check every patient now because of this... I was doing clinicals at a hospital in my area. Patient was brought in, medics said they believed it to be a drug overdose. She had fell down 14 stairs and had a laceration on the back of her head. She had an altered mental status and was vomiting. I was restraining the patient while nurses administered meds, checked vitals, took patient history etc etc., but nobody checked PEARL so after about 35-40 minutes later patient relaxes a little. I didn't like the fact she had head trauma and no one check her pupils, so I went ahead and checked them myself. Come to find out Left Pupil was dilated and Right Pupil was constricted. I told my preceptor and instantly doctors and nurses started filling up the room. RSI was completed and a CAT scan as well. We had the patient for about 3 hours. Patient was finally flown out to another hospital. Ended up being a "brain bleed" as the nurse called it. The next day, I heard she had passed away. I'm still a student and have a lot to learn, with very little experience in the field. But I can't help to wonder if someone would have checked PEARL sooner if she would have made it.


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## mcdonl (Apr 13, 2010)

EMT_TIFFANY said:


> I check every patient now because of this... I was doing clinicals at a hospital in my area. Patient was brought in, medics said they believed it to be a drug overdose. She had fell down 14 stairs and had a laceration on the back of her head. She had an altered mental status and was vomiting. I was restraining the patient while nurses administered meds, checked vitals, took patient history etc etc., but nobody checked PEARL so after about 35-40 minutes later patient relaxes a little. I didn't like the fact she had head trauma and no one check her pupils, so I went ahead and checked them myself. Come to find out Left Pupil was dilated and Right Pupil was constricted. I told my preceptor and instantly doctors and nurses started filling up the room. RSI was completed and a CAT scan as well. We had the patient for about 3 hours. Patient was finally flown out to another hospital. Ended up being a "brain bleed" as the nurse called it. The next day, I heard she had passed away. I'm still a student and have a lot to learn, with very little experience in the field. But I can't help to wonder if someone would have checked PEARL sooner if she would have made it.



Wow. Powerful story. Thanks for sharing that. It could have saved her life maybe....


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## EMT_TIFFANY (Apr 13, 2010)

mcdonl said:


> Wow. Powerful story. Thanks for sharing that. It could have saved her life maybe....



Thanks, it was a hard call because her two young children (like 9 and 13) were in the room throughout all of this.


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## mycrofft (Apr 13, 2010)

*Whoa whoa whoa...opposite pupil NOT opposite response.*

What one eye does the other should also. Same pupillary response. Same motion (that's why you bandage both eyes to try to lessen eye movement). Called consensual eye reactions.

If you see one pupil or occular following differ from the other, do the following:
1. Ask about old hx trauma to eye or head.
2. Do the Falk Test.*
3. Ask if they were related to Imogene Coca.
4. Continue neuro check and assess orientation and LOC carefully. Look for hidden trauma.

(actually, #1 and 4).

*FALK TEST: Actor Peter Falk use to tap on his fake eye with a fork to get a table for himself in the Merchant Marine. Maybe not optimal...


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## Veneficus (Apr 13, 2010)

*It seems like a lot was missed here.*



EMT_TIFFANY said:


> I check every patient now because of this... I was doing clinicals at a hospital in my area. Patient was brought in, medics said they believed it to be a drug overdose. She had fell down 14 stairs and had a laceration on the back of her head.



Did the medics who dx drug overdose know she fell down 14 stairs and had a head lac? 

Demonstrates the need for a proper history and physical. Especially since a scalp wound by itself can be a life threatening bleed.

She may also have ODed on top of it. But that is what UTox screens are for.



EMT_TIFFANY said:


> She had an altered mental status and was vomiting..



Classic head injury presentation with increasing ICP.




EMT_TIFFANY said:


> I was restraining the patient while nurses administered meds, checked vitals, took patient history etc etc., but nobody checked PEARL so after about 35-40 minutes later patient relaxes a little I didn't like the fact she had head trauma and no one check her pupils, so I went ahead and checked them myself...



35-40 mintes with a head trauma an a complete cranial nerve test and neuro eval was not done? What about a CT scan indicated from the history and physical?



EMT_TIFFANY said:


> Come to find out Left Pupil was dilated and Right Pupil was constricted. I told my preceptor and instantly doctors and nurses started filling up the room.



The doctor should turn over his cheque to you for doing his job. If the initial impact was on the back of the head, imagine how much pressure must have been present to cause a lesion to the front/mid section of the brain




EMT_TIFFANY said:


> RSI was completed and a CAT scan as well. We had the patient for about 3 hours.



3 hours?!!! was it snowing? What was going on all that time?




EMT_TIFFANY said:


> Patient was finally flown out to another hospital.



Fortunately. Unless Neuro/critical care surg was making a hole making to relieve the pressure and evacuate the blood.



EMT_TIFFANY said:


> Ended up being a "brain bleed" as the nurse called it. The next day, I heard she had passed away.



Can't say I am surprised by the account of the story. Probably had herniation by the time pupils were checked.



EMT_TIFFANY said:


> I'm still a student and have a lot to learn, with very little experience in the field. But I can't help to wonder if someone would have checked PEARL sooner if she would have made it.



Under ideal circumstances PEARL would have been negative, meaning they discovered the injury prior to it manifesting in a puplilary response.

The gravity of the patients injuries were severely under estimated, the phyisical exam was not properly performed by anyone it sounds like. The PT should not have waited there 3 hours before transfer, transfer should not be delayed for a CT unless you can immediately intervene if you find something, and CT would have been better utilized as an earlier adjunct to the physical exam. 

You did good work, but hospitals like this make me sick.


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## mycrofft (Apr 13, 2010)

*Vene, not uncommon.*

I personally know two or three people who were sent home with S/S intracranial insult and died at home, or had to be emergently rehospitalized.

Also, as you said indirectly, big picture needs to be considered. Don't get target fixated on one  cause, look at the whole picture and do two things: cut to the chase (what needs to be done how fast to prserve life and limb regardless of dx), and starft gathering data for differential dx (what do we and the ER need to know how likely factors a,b,c are to ahve caused this).


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## EMSLaw (Apr 13, 2010)

mycrofft said:


> I personally know two or three people who were sent home with S/S intracranial insult and died at home, or had to be emergently rehospitalized.
> 
> Also, as you said indirectly, big picture needs to be considered. Don't get target fixated on one  cause, look at the whole picture and do two things: cut to the chase (what needs to be done how fast to prserve life and limb regardless of dx), and starft gathering data for differential dx (what do we and the ER need to know how likely factors a,b,c are to ahve caused this).



I agree re: target fixation, but at the same time, as the old saying goes, when you hear hoofbeats, think horses, not zebras.

If the patient suffered a blow to the head, and is presenting with, for example, Cushing's Triad, even an EMT-B should be thinking ICP and rapid transport.  If, as has been noted, the pupils are unequal, then they should know to really start worrying.

I had a "lift assist" call with a fall victim, who presented with unequal pupils.  It turned out, in the end, that he was fine and it was related to a history of eye surgery, but that wasn't clear on scene (we asked, nobody knew if it was normal for him, despite having just seen the eye doctor.). Despite the false alarm, the ER had no complaints about the alarm being sounded in the first place.


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## Veneficus (Apr 13, 2010)

mycrofft said:


> I personally know two or three people who were sent home with S/S intracranial insult and died at home, or had to be emergently rehospitalized.
> 
> Also, as you said indirectly, big picture needs to be considered. Don't get target fixated on one  cause, look at the whole picture and do two things: cut to the chase (what needs to be done how fast to prserve life and limb regardless of dx), and starft gathering data for differential dx (what do we and the ER need to know how likely factors a,b,c are to ahve caused this).



You would think nobody learned anything in ATLS class.

Sadly you are right, it is common. It is the exact reason EMS providers are told to take trauma patients to the trauma center, bypassing facilities if need be. 

I worked for years in a major trauma center, it is also the focus of my career, in my opinion if you have a serious injury and you get taken to a community hospital, there are one of 2 outcomes. You will either be transferred right away, or you will lay there dying until you are beyond help by mortals.


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## xgpt (Apr 13, 2010)

Veneficus said:


> You would think nobody learned anything in ATLS class.
> 
> Sadly you are right, it is common. It is the exact reason EMS providers are told to take trauma patients to the trauma center, bypassing facilities if need be.
> 
> I worked for years in a major trauma center, it is also the focus of my career, in my opinion if you have a serious injury and you get taken to a community hospital, there are one of 2 outcomes. You will either be transferred right away, or you will lay there dying until you are beyond help by mortals.



Isn't that protocol? (I've only been on two calls...but I thought that was protocol)


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## mycrofft (Apr 13, 2010)

*Calling Natasha Richardson*

Pt fell, but what caused the fall? Did they experience a CVA leading to the fall (could be embolic or haemorrhagic) or did they trip on the dog and strike head (almost certainly haemorrhagic)?  ETOH? Meds?Agreed, watch for horses not unicorns, and the data should rapidly point to the most likely dx.


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## alphatrauma (Apr 15, 2010)

mycrofft said:


> Pt fell, but what caused the fall? Did they experience a CVA leading to the fall (could be embolic or haemorrhagic) or did they trip on the dog and strike head (almost certainly haemorrhagic)?  ETOH? Meds?Agreed, watch for horses not unicorns, and the data should rapidly point to the most likely dx.




^ this


I would also querry as to whether the patient would've had a positive outcome at all... pupils checked or not. Midline shift and herniation do not progress as rapidly as one would think, (barring pharmacological, pathological history) in healthy individuals, from a fall as described. If the patient was bleeding that badly, from the time EMS made first contact to the time she was in hospital (roughly an hour according to the timeline), it was a foregone conlusion. 

Am I excusing or condoning the omission in assessment... no. But the argument in this case seems to be moot


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## Pneumothorax (Apr 15, 2010)

jtpaintball70 said:


> There's allso PERLA (Pupils Equal and Reactive to Light and Acomidating)



i thought the A meant adjacent.

i could be wrong *shrug*


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## JPINFV (Apr 15, 2010)

A stands for "accomodation."


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## mycrofft (Apr 15, 2010)

*Answering the title (my mental passtime)*

"Oh, Mondays between seven and twelve".

PERLA check is good, but serial checks are better. Timed and recorded serial checks are best. Change is not always good.


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## EMSLaw (Apr 15, 2010)

Pneumothorax said:


> i thought the A meant adjacent.
> 
> i could be wrong *shrug*



You probably don't need a penlight to tell if the eyes aren't adjacent.


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## Akulahawk (Apr 15, 2010)

EMSLaw said:


> You probably don't need a penlight to tell if the eyes aren't adjacent.


Yah. If someone's eyes weren't adjacent, then perhaps I'm really treating a chameleon... or someone whose head has been cleaved. I'd just have to call him "Cleaver"... or... 

Anyway, I used to check PERRLA whenever I did check the GCS, and of course, document the findings... That's two tasks that I can combine together and not have it take up too much extra time.


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## JPINFV (Apr 15, 2010)

EMSLaw said:


> You probably don't need a penlight to tell if the eyes aren't adjacent.



To be fair, you generally don't really need a pen light to check PEARL and definitely don't need one to check accomodation.


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## reaper (Apr 16, 2010)

JPINFV said:


> To be fair, you generally don't really need a pen light to check PEARL and definitely don't need one to check accomodation.



Bingo!

If you are in a well light area, all you have to do is cast a shadow over their face to see the pupils react. Half the time I never have to use a flashlight to check pupils.


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## Akulahawk (Apr 16, 2010)

If you don't have a penlight... just use the 100,000 candlepower spotlight in the truck... :blink:


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## mycrofft (Apr 17, 2010)

*Three words:*

Green laser pointer.

Fix those pesky retinal tears too.


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