Possible Stroke, yet not?

[DesertMedic66]

Since we're throwing out random differentials for "unequal pupils," presumably to light (did you check accommodation?) it could be syphilis.

No posts from you for a long time and you come back with "it could be syphilis". Good job sir :rofl:

 

[Melclin]

Normal variant.

As others have said, the blown pupil in strokes don't happen in the otherwise asymptomatic patient. If they're sitting there talking to you, otherwise asymptomatic, with a pupil 1mm bigger than the other, you can probably relax about the stroke stuff as far as I know.

Something else worth mentioning if we're talking about pupils and maybe-sorta stroke symptoms, horner's syndrome is something to google.

 

[Brandon O]

As a rule:

Big badness = many findings
One, isolated finding = not a big badness

"Honey, did a meteor wipe out New York?"
"I doubt it, why?"
"Well, The Daily Show website isn't loading."

 

[Eli]

I am a little hesitant to answer a question like this from a "student". I would not want to say anything that might contradict the direction of his classroom training. For now, the main goal is not to save a life but to pass the state test.

With that being said... We are basically looking at what is going to kill this guy? Is there something we can do that might improve or decrease is odds. That's why you're concerned about the possibility of a stroke. Some of the treatment for a patient with acute coronary syndrome might be harmful to a patient having a stroke.

When you say the medic did an ECG, I am going to assume you mean a 12 lead and not simply a 4 lead. The biggest reason why "MONA" can be harmful to a patient having a stroke is when there is active bleeding going on around the brain. Often these types of strokes are catastrophic. They don't normally come with teeny tiny signs here and there.

Of all the things that we do for patients with ACS, there only two things that we do that reduces mortality. Aspirin for all types of AMI's is one. The other is reducing the time is takes to get a patient with a STEMI to the cath lab. Everything else is a good idea but doesn't reduce mortality from a statistical perspective.

So decision time. Small chance of a hemorrhagic stroke based on exam. Assuming again that a 12 lead was done, there is no evidence of a STEMI. What are the treatment choices? Oxygen, an IV, Nitro seem safe enough in either case. Transport. To where. Does he need a stroke center? Does he need an emergency cardiac cath? Refer to your local protocols, but with mine the answer is no. He doesn't meet criteria for either. So any reasonable destination would do. That leaves aspirin. You will get a lot of supporting arguments for giving or withholding it. I personally would probably give it. But if I'm sitting on the fence I wouldn't hesitate to contact medical control and discuss it with a physician.

When it all boils down, our choices in EMS are often pretty simple. It's just a matter of learning the decision trees. Great job on the assessment by the way!

 

[Ewok Jerky]

Cranial Nerve III lesion affecting ciliary body. We should investigate the other functions of CN III need to check accommodation and extra-ocular movements. Did you notice any eyelid drooping on the affected side?

...or just a normal variant. But definitely not a stroke.

 

[fma08]

Cranial Nerve III lesion affecting ciliary body. We should investigate the other functions of CN III need to check accommodation and extra-ocular movements. Did you notice any eyelid drooping on the affected side?

...or just a normal variant. But definitely not a stroke.

Parasympathetics control the ciliary body which alters the lens shape. They also control the sphincter pupillae which dictates pupil size. CN-III is eye movements. But seeing as they are closely related anatomically, I guess that's just me being nitpicky.

That being said, his BP is not good and with blurry vision along with the unequal pupils, he warrants a bit more of a neuro exam before chalking it up to a "normal variant". Although, this can be done on the way to the hospital after looking into the chest pain and the obvious signs of a stroke, which it sounds like you did, so good job.

 

[Mariemt]

Ahhhh my first assessment as a student had unequal pupils... and non reactive at that.

However she wasn't being seen in an emergency setting. She had some eye issue and an old injury or something

If he no longer had chest pain. What was the chief complaint? The chest pain had been there for a week, but went away before he called? Or after you got there?

 

[Ewok Jerky]

Parasympathetics control the ciliary body which alters the lens shape. They also control the sphincter pupillae which dictates pupil size. CN-III is eye movements. But seeing as they are closely related anatomically, I guess that's just me being nitpicky.

That being said, his BP is not good and with blurry vision along with the unequal pupils, he warrants a bit more of a neuro exam before chalking it up to a "normal variant". Although, this can be done on the way to the hospital after looking into the chest pain and the obvious signs of a stroke, which it sounds like you did, so good job.

You are correct that pupil size is controlled by the parasympathetic autonomic nervous system. In this case the parasympathetic pathway is through CN III. In addition, loss of oculomotor control will cause diplopia.

You were also right in that I said ciliary body when I meant spincter pupillae.

 

[Dwindlin]

Pupillary size is a function of both limbs of the ANS.