Disclaimer: This is intended as a general information guide for trained professionals. This information is NOT intended to be a substitute or replacement of proper training and education related to these topics. Austere Environments LLC does not guarantee the accuracy or effectiveness of the information contained herein.
Normally, both pupils are the same size, from 2-6 mm. Size of pupils should be assessed after the eyelids have opened and the pupils have accommodated to room light. Approximately 17% of the population have unequal pupils and this is a normal finding for them. Direct eye injury or past surgery can affect size.
Pupils can be described according to their size (mm) or by description:
Pinpoint: Opiate overdose or pontine hemorrhage
Small: Evident in bright room. Pontine hemorrhage, Horner’s syndrome, metabolic coma.
Midposition: Normal light conditions. Non-reactive could indicate mid-brain damage.
Large: Evident in low light/dark conditions. Apparent with certain drugs or certain orbital injuries
Dilated: Always an abnormal indicator. Bilateral, fixed and dilated pupils are seen in the terminal stage of severe terminal anoxiaischemia or at death. Anti-Cholinergic drugs can dilate pupils.
Normal: Equal gaze and tracking. Symmetrical movement and reactivity to light.
Pupils are normally round in shape. Here are some examples of possible abnormally shaped pupils with their potential causes.
Ovoid: Almost always an indicator of intracranial hypertension and can be associated with early sign of transtentorial herniation. Ovoid pupil represents the intermediate phase between a normal pupil and a fully dilated and fixed pupil.
Keyhole: Seen in patients with cataract surgery. Reactivity to light is usually sluggish.
Irregular: May be present with traumatic orbital injury.
To assess for reactivity, make sure that the light in the room is dim. Bring light source in from the side of the eye towards the pupil. Using the light beam to “splash” the light source from the side of the eye, never directly into the pupil.
Normally, pupils briskly constrict to light and briskly dilate when light sources are removed. Pupils tend to be larger and more reactive in younger people.
Pupils can also react in the following manner:
Sluggish: found in conditions that compress the third cranial nerve, such as, cerebral edema and herniation.
Nonreactive or Fixed: seen in conditions that compress the 3rd cranial nerve such as herniation, severe hypoxia and ischemia
Hippus phenomenon: with uniform illumination of the pupil, alternating dilation and contraction of the pupil occurs. This is often associated with early signs of transtentorial herniation or may indicate seizure activity.
What to expect in a normal healthy person:
- The eyes blink periodically.
- The eyes move together in the orbital sockets.
- No nystagmus or abnormal eye movements.
- The eyeball neither protrudes or is sunken into the eye socket.
- Eyelid droop is not present.
Pupils, Equal, Round, Reactive, Light
If a patient is in true coma and you lift their eyelids and let them go, they will gradually cover the eyes. If a patient is in a hysterical coma and you lift their eyelids, the lids will rapidly close.
Involuntary movement of an eye which may be horizontal, vertical, rotary or mixed. It can result from many different problems. If it is present you should document what it looks like e.g. fast horizontal movement, circumstances that seemed to have caused it, when it started.
- Horizontal gaze nystagmus is often an indicator of alcohol impairment.
- Vertical gaze nystagmus is an indicator of high levels of alcohol or drug ingestion
Suture Size vs Wound Size: Determining what to Use
Determining wound size will help determine if a patient will need sutures, staples, or none of the mentioned. Commonly, width, length, and depth of a wound is measured in centimeters or inches; most commonly, a provider will use a suture somewhere between sizes 3-0 and 6-0 (the bigger the number, the smaller the suture). Small sutures(5-0 and 6-0) are used on the face. Larger sutures(3-0 and 4-0) are best for areas where appearance is not of great concern such as the extremities. Wounds that typically will get some type of external closures meet the following criteria:
- Wounds that are more than 0.25 in. (6.5 mm) deep, that have jagged edges, or that gape open.
- Wounds wider than 0.75 in. (20 mm) that are deeper than 0.25 in. (6.5 mm).
- Deep wounds that go down to the fat, muscle, bone, or other deep structures.
- Deep wounds over a joint, especially if the wound opens when the joint is moved or if pulling the edges of the wound apart shows fat, muscle, bone, or joint structures.
- Deep wounds on the hands or fingers.
- Wounds on the face, lips, or any area where you are worried about scarring (for cosmetic reasons). Wounds on the eyelids often need treatment for both functional and cosmetic reasons.
- Wounds that continue to bleed after 15 minutes of direct pressure.
Stanford University Neurological Assessment
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