Weird pupil dilation

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Emergency Metaphysics

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Hello all,

A little background: I've been a paramedic now for 2 whole weeks, which means I know just enough to be dangerous at this point. My partner and I had a patient last shift who exhibited a pupil reaction I've never seen before, and I'm wondering if any of you have observed this or not and what you did -- if anything -- in the way of patient care. Pt presented to our ambulance by getting into the driver's seat while I was in the back with another patient. This new pt is in the driver's seat, dressed in a pink nightgown, and is clearly disoriented and not responding to my partner's questions. This woman goes unresponsive and incontinent right then and there. Blood sugar is fine. Pt is hypertensive. This is at night, so when the pt's eyes are opened and light is shone into them, the pupils DILATE rather than CONSTRICT in response to the light. Everyone on scene was like, "Well, that's weird." Any ideas what would cause a pt's pupils to dilate to light rather than constrict?

Cheers.
 
Underoath87 said:
With a bit of Googling, I just came up with: Afferent pupillary defect or Marcus Gunn pupil.
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Not the same thing.

I don't know of anything that would cause true dilation to light. Might have been a visual illusion.
 
Brandon O said:
Not the same thing.

I don't know of anything that would cause true dilation to light. Might have been a visual illusion.
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Yeah, I wasn't satisfied by the Google results I got when I did some quick research, which is why I posted here. And as far as an "illusion": it would be difficult to say it was an illusion when veteran medics were the one's who first saw this happen. It was so strange to see. I'm well-aware that pupils can be both dilated, both constricted, or some variation of different sizes depending on what is going on with the patient, but to actually see such an unexpected result took me back. I'm going to see if I can follow up with the patient's progress and report back what I learn in the most HIPAA-compliant way possible.

Cheers,
M.
 
Seizure can look like this. Autonomic activity during a seizure can cause dilation or constriction regardless of the normal pupillary light reflex. And partial seizures may not have the associated tonic-clonic movements you associate with grand mal seizure. The loss of continence may also be a clue that this patient had a partial seizure.

Typically during the post ictal period, the pupillary light reflex returns to normal, though may be sluggish.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC531654/
 
Nova1300 said:
Seizure can look like this. Autonomic activity during a seizure can cause dilation or constriction regardless of the normal pupillary light reflex. And partial seizures may not have the associated tonic-clonic movements you associate with grand mal seizure. The loss of continence may also be a clue that this patient had a partial seizure.

Typically during the post ictal period, the pupillary light reflex returns to normal, though may be sluggish.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC531654/
Click to expand...

This is what I thought also, as soon as I read it. The patient becoming unresponsive and incontinent smells like a seizure. (No pun...well, okay... It was intended) Perhaps the impending aura led her to you. How fortuitous. Any chance for follow up with the emergency department after this? Did she ever become conscious enough for you to get any history from? The whole "she climbed into the front seat of the ambulance" is a little odd to me. Was she in residence at the house of the patient you were currently treating? Or did she just randomly show up?
 
There is really no way of knowing without additional information about her medications & medical history. I have seen patients with migraines, seizures & increased cranial pressure develop changes in their pupils. Based on what you have told us, it sounds like a seizure.
 
Nova1300 said:
Seizure can look like this. Autonomic activity during a seizure can cause dilation or constriction regardless of the normal pupillary light reflex. And partial seizures may not have the associated tonic-clonic movements you associate with grand mal seizure. The loss of continence may also be a clue that this patient had a partial seizure.

Typically during the post ictal period, the pupillary light reflex returns to normal, though may be sluggish.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC531654/
Click to expand...


Thanks much for this. I appreciate the input. I haven't yet had a chance to follow up with the patient.
 
DEmedic said:
This is what I thought also, as soon as I read it. The patient becoming unresponsive and incontinent smells like a seizure. (No pun...well, okay... It was intended) Perhaps the impending aura led her to you. How fortuitous. Any chance for follow up with the emergency department after this? Did she ever become conscious enough for you to get any history from? The whole "she climbed into the front seat of the ambulance" is a little odd to me. Was she in residence at the house of the patient you were currently treating? Or did she just randomly show up?
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Hello! I haven't yet had a chance to follow up on this patient. I think she might have been transferred to another hospital, but I'm not certain. She was indeed a resident of the same building our first patient was in. She was completely out of it, nonverbal, then unconscious and incontinent. So strange. She never regained an LOC to allow for an interview while in my partner's care. But yep, she just opened the door, sat in the driver's seat, stared at my partner, and then down she went.
 
Emergency Metaphysics said:
She was completely out of it, nonverbal, then unconscious and incontinent. So strange. She never regained an LOC to allow for an interview while in my partner's care.
Click to expand...
It very well could be that she was postictal from a prior seizure, was disoriented as a result, found her way to your ambulance and had another seizure... and seizures can present in ways other than the stereotypical tonic-clonic that we are well aware of. This also kind of "smells like" a seizure, the question is what precipitated it?
 
I just saw this the other day. Or rather, the ED doc did after we dropped her off. She had no neuro deficits when we dropped her off.
Same story. Very hypertensive, 250/130. Shortly after they saw the pupil reaction she seized. CT was negative for any acute findings.
 
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