When To Check PEARL

[pirate000]

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

 

[JPINFV]

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).

 

[emt_irl]

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)

 

[EMSLaw]

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.

 

[TransportJockey]

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

 

[bstone]

Always check PEARRL.

 

[EMSLaw]

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

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

 

[TransportJockey]

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.

 

[LondonMedic]

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...

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.

 

[JPINFV]

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.

 

[emt_irl]

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

 

[mcdonl]

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

 

[EMT_TIFFANY]

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.

 

[mcdonl]

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....

 

[EMT_TIFFANY]

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.

 

[mycrofft]

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...

 

[Veneficus]

It seems like a lot was missed here.

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.

She had an altered mental status and was vomiting..

Classic head injury presentation with increasing ICP.

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?

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

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?

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.

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.

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.

 

[mycrofft]

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).

 

[EMSLaw]

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.

 

[Veneficus]

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.