Possible Stroke, yet not?

[cointosser13]

I recently had a call where this guy was having chest pain. He said it had been going on for a week, so my unit wasn't too worried about it. When we got the patient into the ambulance, I did a physical exam, checking his lungs sounds and all. When I got to the pupils, I realized that they were unequal. :blink: I got a little nervous because when I checked the BP in the house, it was something like 178/102. I suspected this guy was having a stroke, and the least of my problems at the moment was the chest pain. I asked the patient "Have you had any recent cataract surgery?" The patient stated, "No". I did the Cincinnati Stroke Test, but they were all negative!?? The guy did state that his vision was a little bit blurry. He was in his 50's, so I took that into consideration.

Now my question is, what could be the explanation for the unequal pupils if the patient didn't have recent cataract surgery, or other signs of a stroke? My partner told one of the Docs about the situation, and he later told me "Apparently, 15% of people in this world have unequal pupils". But why? Is it that when you get older your eyes just go all wacko on you? I'm an EMT basic, so if you medics know something I don't know, please tell me.

 

[rmabrey]

I don't have any specifics as to why, but yes, a small percentage of the population does have unequal pupils. It shouldnt be a difference of anymore than 1mm for the most part

 

[teedubbyaw]

Did he have a history of hypertension?

 

[cointosser13]

No history of hypertension. He wasn't even taking any medication.

 

[NPO]

Also a basic, and just speculating. But who's to say he didn't have a thrombosis localized to the occipital lobe.

 

[Aprz]

Wikipedia anisocoria

 

[Handsome Robb]

My medic program coordinator's eyes are like that. Looks like she has a massive head injury all the time. Usually ~2mm difference.

For what it's worth, generally a patient with a stroke or CHI bad enough to blow a pupil they won't be a&o if they're even conscious.

There's a reason out trauma pre-alert protocol specifies "an unresponsive trauma patient with a unilateral blown pupil."

 

[msjellybean]

About two years ago, I noticed that suddenly my right pupil was anywhere from 1-2mm bigger than my left. Being a neuro RN, this scared the bejesus outta me. Went to multiple doctors and I'm fine. Just developed anisocoria somehow.. no family history or anything.

Mine usually isn't that noticeable, unless I'm really tired or have a migraine. In which case, it looks like I've blown my pupil. But once it resolves, it goes back to it's usual size.

Sorry I don't have anything to contribute relating to the call.

 

[Dwindlin]

Also a basic, and just speculating. But who's to say he didn't have a thrombosis localized to the occipital lobe.

Occipital lobe doesn't control pupil size and a injury in this area is likely to cause visual deficits, not blurriness. Blurriness is more likely a lens problem or (less likely) a subtle disconjugate gaze.

 

[jwk]

I recently had a call where this guy was having chest pain. He said it had been going on for a week, so my unit wasn't too worried about it. When we got the patient into the ambulance, I did a physical exam, checking his lungs sounds and all. When I got to the pupils, I realized that they were unequal. :blink: I got a little nervous because when I checked the BP in the house, it was something like 178/102. I suspected this guy was having a stroke, and the least of my problems at the moment was the chest pain. I asked the patient "Have you had any recent cataract surgery?" The patient stated, "No". I did the Cincinnati Stroke Test, but they were all negative!?? The guy did state that his vision was a little bit blurry. He was in his 50's, so I took that into consideration.

Now my question is, what could be the explanation for the unequal pupils if the patient didn't have recent cataract surgery, or other signs of a stroke? My partner told one of the Docs about the situation, and he later told me "Apparently, 15% of people in this world have unequal pupils". But why? Is it that when you get older your eyes just go all wacko on you? I'm an EMT basic, so if you medics know something I don't know, please tell me.

So what did you do about his chest pain? Or did you get totally sidetracked by the unequal pupils which may or may not have been significant?

One thing to remember - is someone has atherosclerotic arteries, they're liable to have them in a number of places. That means if they have plaques in their coronaries, they likely have them in their carotids as well, and vice versa.

 

[NPO]

Would you treat the chest pain? With no EKG to confirm MI would aspirin or nitro be contraindicated due to possibility of stroke?

 

[shfd739]

One thing to remember - is someone has atherosclerotic arteries, they're liable to have them in a number of places. That means if they have plaques in their coronaries, they likely have them in their carotids as well, and vice versa.

This^

The unequal pupils isn't enough to take me away from treating the chest pain. A single pupil change with no other symptoms isn't enough for me to call stroke.

I have seen a few folks that after having an MI/failing a stress test and getting stents placed showed visual improvements and eye deteriorations reversed themselves.



Though anecdotal I have seen

 

[shfd739]

Would you treat the chest pain? With no EKG to confirm MI would aspirin or nitro be contraindicated due to possibility of stroke?

EKGs do not always confirm MI. Could be an MI with no EKG changes-seems I remember something like 50% of MIs do not show on an EKG. Anecdotal I know but when my dad had a 100% occlusion/MI he went into vfib, was defibrillated back to a sinus rhythm, had a stent placed and never had an EKG change.

EKG is more of a rule in than a rule out and id keep a suspicion up until further testing is done.

 

[Handsome Robb]

EKGs do not always confirm MI. Could be an MI with no EKG changes-seems I remember something like 50% of MIs do not show on an EKG. Anecdotal I know but when my dad had a 100% occlusion/MI he went into vfib, was defibrillated back to a sinus rhythm, had a stent placed and never had an EKG change.

EKG is more of a rule in than a rule out and id keep a suspicion up until further testing is done.

Agreed. Hence why even with a "normal" ECG my line is, "electrically your heart looks great. With that said, unfortunately The only definitive answer is a lab draw which I cannot do so we need to go to the hospital."

ECGs are great when combined with a good assessment to build the big picture.

I have BER, I sit in the 50s and 90s/50s. I have an ECG of myself with my vitals that I always give to paramedic students and ask them, "without knowing anything else, what's your first thought?" Nearly every student answers with, "an inferior MI with possible RVI!" The looks or their faces are priceless when I tell them that's me. Really drives home the point of a good assessment in combination with our qualitative and quantitative assessment tools.

 

[NPO]

EKGs do not always confirm MI. Could be an MI with no EKG changes-seems I remember something like 50% of MIs do not show on an EKG. Anecdotal I know but when my dad had a 100% occlusion/MI he went into vfib, was defibrillated back to a sinus rhythm, had a stent placed and never had an EKG change.

EKG is more of a rule in than a rule out and id keep a suspicion up until further testing is done.

Ahh. Good point. I didnt mean to use the word 'CONFIRM' because that is a tough word in the prehospital setting, but you know what I mean.

However I do want to point out that if he went into vfib he did have an EKG change but your point is understood

 

[shfd739]

Ahh. Good point. I didnt mean to use the word 'CONFIRM' because that is a tough word in the prehospital setting, but you know what I mean.

However I do want to point out that if he went into vfib he did have an EKG change but your point is understood

Lmao true.

 

[the_negro_puppy]

As others have said there are many conditions and injuries that can influence pupil appearance.

In a head injury / CVA unequal pupils is a very late sign of raised ICP. You will have many more signs and symptoms other than htn.

 

[cointosser13]

So what did you do about his chest pain? Or did you get totally sidetracked by the unequal pupils which may or may not have been significant?

One thing to remember - is someone has atherosclerotic arteries, they're liable to have them in a number of places. That means if they have plaques in their coronaries, they likely have them in their carotids as well, and vice versa.

The patient did state that he was no longer having any chest pain. All his vitals were WNL. We did connect him to a EKG just in case, and the medic said there was nothing wrong with the heart. Everything was normal.

I think he was just one of the 15% who have anisocoria. The chest pain, I don't know why he was having that. Could eating spicy food cause any form of chest pain? I think it would bother the stomach more than anything else.

 

[Aidey]

How does food get to the stomach? Where exactly is the stomach located?

 

[JPINFV]

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