A case study
Lauren Walker, RN, BSN, CCRN

On 4/7/11 a 19 year-old-male with no
significant PMH presented to an OSH after
the onset of a severe HA.
• At the OSH, the pt became unresponsive, was
intubated and sent to CT
•He was then transferred to GUH for a large right
intracerebral hematoma



Neuro: no sedation, no eye opening, R pupil
6mm and nonreactive, L pupil 3mm and
sluggish by manual exam, not following
commands, MAE non-purposely.
Resp: Intubated, unlabored, clear lung sounds
bilaterally, O2 Sats stable.
CV: HR regular, VSS, afebrile, 2+ pulses
bilaterally, CRT less than 3 seconds.

MD:
 Right Eye: 6mm and Fixed
 Left Eye: 3mm Fixed

RN
 Right Eye: 8mm and Fixed
 Left Eye: 3mm Sluggish
Why is this admission exam so different when taken at
the same time?

4/7/11: Admitted to NSICU for a Large right side Hematoma
 OR for right side craniotomy, hematoma evacuation and EVD placement

Continued to have high ICPs over the next few days despite ICP
management and EVD

4/11/11: CT- malignant cerebral edema

4/11/11: OR for Right Craniectomy

4/22/11: Traceostomy

4/25/11: G-Tube Placement

Eventually transferred to an outside facility with a poor neurologic
outcome.

Manual pupil exam had different
measurements each shift

It took several days and several operations
since admission to get stabilized ICPs.

What can we use on the floor for an
objective neurologic exam?
“Performing frequent pupil assessments
provides critical and time-sensitive information
regarding new or worsening intracranial
pathology; therefore, an accurate examination
is essential”.
“Automated Pupillometer may be useful in
providing ICU nurses with a precise and
reliable measurement or pupil size and
reactivity.”
Meeker M, Du R, Bacchetti P, Privitera C, Larson M, Holland M, Manley G. (2005). Pupil
examination: Validity and clinical utility of an automated pupillometer. Journal of Neuroscience
Nursing, 37(1).
“Using NPi there was an inverse relationship
between decreasing pupil reactivity and
increasing ICP.”
“Using NPI may be a useful tool in the early
management if pts with causes of increased
ICP.”
Chen J., Gombart Z., Rogers S., Gardiner S., Cecil S., Bullock R. (2011). Pupillary
reactivity as an early indicator of increased intracranial pressure: The introduction of
neurologic pupil index. Surgical Neurology International, 2(1), 82-86.
“The development of a portable, automated,
infrared Pupillometer has recently transformed
pupillary parameter measuring from a
subjective and highly variable methodology to
an accurate and reproducible one”.
“Meticulous standardization of the technique
can minimize the observed variations”.
Fountas, K., Kapsalaki, E., Machinis, T., & Boev, A. (2006). Clinical implications of
quantitative infrared pupillometry in neurosurgical patients. Neurocritical Care,5
Taylor, W., Chen, J., Meltzer, H., Gennarelli, T., Kelbch, C., Knowlton, S., . . . Marshall, L. (2003).
Qualtitative pupillometry, a new technology: Normative data and preliminary observations in
patients with acute head injury. J Neurosurg, 98, 205-213.
“The pupillometer is a reliable and safe
method that provides detailed and accurate
information regarding patterns of pupillary
responsiveness”.
“Early detection of changes in brain volume
with the use of the Pupilometer may reduce
the mortality rate”.

Does our patient’s Pupillometer readings
correlate with the literature?
Parameter
Normal
Reportable Condition
% Pupil Change
(% Change)
Greater than 10%
Less than 10%, a decrease in pupil
change is suspicious of intracranial
dynamics
Constriction Velocity (CV)
Greater than 0.8 mm/sec
Less than 0.8 mm/sec = an
increase in brain volume
Less than 0.6mm/sec correlates
with an ICP > 20
NPI
Greater than or equal
than 3
Closer to 5 is more brisk
Other values that are measured:
•MIN/MAX aperture
Less than 3 is a weaker than
normal pupil reaction
26
24
22
20
18
16
14
12
10
8
6
4
2
0
Figure 2. Left Eye Pupillometer Readings, POD 3
Craniotomy, 4/10/11
Reading
Reading
Figure 1. Right Eye Pupillometer Readings. POD 3
Craniotomy, 4/10/11
ICP
CV
% Change
1
2
3
4
5
6
Hours
7
8
9
10
NPI
26
24
22
20
18
16
14
12
10
8
6
4
2
0
ICP
CV
% Change
1
2
3
4
5
6
7
8
9
10
Hours
Interventions to decreased ICP also cause an increase in % Change
CV was low in both eyes- especially in left eye indicating ICP.
Interventions did not control ICP throughout the day
Sedated on a Propofol gtt (80mg/hr), Fentanyl gtt (500 mcg/hr)
Paralyzed on Vecuronium gtt (1.2 mg/hr)
NPI
4/10/11 Right Eye Max/Min
ICP
24
19
17
16
19
12
15
11
15
14
MAX
3.04
2.9
2.97
2.86
2.82
2.81
2.79
2.74
2.8
2.73
MIN
2.9
2.78
2.84
2.73
2.59
2.59
2.54
2.49
2.51
2.49
4/10/11 Left Eye Max/Min
NPI
3
3.1
3
3.2
3.6
3.6
3.7
3.8
3.8
3.9
ICP
24
19
17
16
19
12
15
11
15
14
MAX
2.49
2.65
2.59
2.6
2.55
2.56
2.63
2.54
2.59
2.58
MIN
2.41
2.59
2.52
2.54
2.51
2.48
2.49
2.42
2.54
2.45
NPI
3.1
3.1
3.2
3.1
3.3
3.5
3.1
3.5
3.3
3
RN Documented bilateral pupil response through the day to be 3 and fixed.
Pupillometer recorded pupil to be 2.5-3 with a normal reaction to light
40
38
36
34
32
30
28
26
24
22
20
18
16
14
12
10
8
6
4
2
0
↙ Hydrazaline
↑RR
↙OR: Hemicraniotomy
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Hours
40
38
36
34
32
30
28
26
24
22
20
ICP
18
16
CV
14
% Change 12
10
8
NPI
6
4
2
0
Figure 4. Left Eye Pupillometer Readings, POD 4 Craniotomy,
POD 0 Hemicrani, 4/11/11
↙ Hydrazaline
↑RR
ICP
CV
% Change
↙OR: Hemicraniotomy
NPI
Reading
Readings
Figure 3. Right Eye Pupillometer Reading, POD 4
Craniotomy, POD 0 Hemicrani, 4/11/11.
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16
Hour
As ICP increases, % change decreases- less
CV has been low for now for 24 hours- we
than 10 is indicative of IC dynamics
have objective data that correlates with
high ICP and brain damage. How can we use
As ICP decreases, % change increasethis information to influence decision
showing a normal pupil response to light
making at the bedside?
Sedated on a Propofol gtt (80mg/hr), Fentanyl gtt (500 mcg/hr)
Paralyzed on Vecuronium gtt (1.2 mg/hr)
4/11/11 Right Eye Max/Min
ICP
MAX
4
37
17
14
5
6
7
6
6
13
14
9
12
12
12
12
2.8
2.84
2.68
2.73
2.62
2.67
2.59
2.6
2.63
2.55
2.52
2.48
2.76
2.65
2.67
2.66
MIN
4/11/11 Left Eye MAX/MIN
NPI
2.44
2.52
2.59
2.51
2.32
2.35
2.28
2.35
2.17
2.2
2.19
2.2
2.33
2.3
2.29
2.34
4
3.9
3.2
3.7
4.1
4.1
4.1
3.9
4.5
4.2
4.3
4.2
4.2
4.2
4.2
4.1
ICP
MAX
MIN
NPI
4
2.55
2.46
37
2.67
2.61
17
2.6
2.52
14
2.66
2.59
5
2.53
2.25
6
2.63
2.53
7
2.63
2.58
6
2.61
2.51
6
2.6
2.44
13
2.55
2.43
14
2.6
2.45
9
2.58
2.48
12
2.63
2.52
12
2.6
2.48
12
2.68
2.54
12
2.98
2.71
3.3
3
3.3
3.1
3.1
3.4
3.1
3.3
3.6
3.5
3.6
3.5
3.4
3.4
3.4
3.5
RN Manual Exam: Right and Left Eyes 3 and fixed
Pupillometer: Right Eye: 2.22-2.8 and brisk, Left Eye: 2.5-2.98 and normal
reaction to light
Figure 6. Left Eye Pupillometer Readings. POD 5
Craniotomy, POD 1 Hemicrani 4/12/11
18
16
14
12
10
8
6
4
2
0


16
14
12
ICP
CV
Readings
Reading
Figure 5. Right Eye Pupillometer Readings, POD 5
Craniotomy, POD 1 Hemicrani, 4/12/11
10
ICP
8
CV
6
% Change
4
%Change
NPI
2
NPI
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 192021
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 192021
Hours
Hours
Again, we can clearly see the relationship of ICP as it relates to % change in the pupil.
There is evidence of left side permanent damage most likely due to pressure displaced on the
ocular motor nerve
Sedated on a Propofol gtt (80mg/hr), Fentanyl gtt (500 mcg/hr)
Paralyzed on Vecuronium gtt (1.2 mg/hr)
4/12/11, POD 5 Right Eye MAX/MIN/NPI
ICP
MAX
MIN
NPI
12
2.61
2.33
12
2.62
2.26
12
2.64
2.33
10
2.61
2.27
RN Manual Exam:
11
2.64
2.24
Right: 3.5, brisk
11
2.59
2.35
Left: 3, sluggish
11
2.72
2.36
9
2.6
2.32
9
2.65
2.34
Pupilometer Exam:
10
2.54
2.33
Right: 2.5-2.7, brisk
15
2.63
2.34
15
2.67
2.34
Left: 2.5-2.9, normal
10
2.63
2.36
(but less brisk than
11
2.7
2.44
right- not sluggish)
10
2.7
2.45
9
2.58
2.2
10
2.65
2.2
13
2.66
2.32
13
2.55
2.24
12
2.69
2.35
12
2.62
2.29
4/12/11, POD 5 Left Eye MAX/MIN/NPI
4
4.3
4.1
4.2
4.4
3.9
4.2
4.1
4.1
3.9
4.1
4
4
3.9
3.9
4.3
4.4
4.1
4.1
4.1
4.1
ICP
12
12
12
10
11
11
11
9
9
10
15
15
10
11
10
9
10
13
13
12
12
MAX
2.69
2.66
2.64
2.65
2.65
2.65
2.61
2.63
2.64
2.64
2.63
2.61
2.55
2.83
2.93
2.6
2.82
2.65
2.59
3.37
2.9
MIN
2.51
2.56
2.53
2.59
2.5
2.53
2.46
2.53
2.58
2.59
2.56
2.46
2.43
2.66
2.69
2.44
2.59
2.44
2.42
2.93
2.59
NPI
3.6
3.2
3.4
3.4
3.5
3.4
3.5
3.3
3.3
3.3
3.2
3.5
3.3
3.4
3.6
3.6
3.7
3.7
3.6
3.4
3.8
22
20
18
16
14
12
10
8
6
4
2
0
Figure 8. Left Eye Pupillometer Readings. POD 6
Craniotomy, POD 2 Hemicrani, 4/13/11.
ICP
CV
Readings
Readings
Figure 7. Right Eye Pupillometer Readings. POD 6
Craniotomy, POD 2 Hemicrani, 4/13/11.
%CH
NPI
18
16
14
12
10
8
6
4
2
0
ICP
CV
% Change
NPI
1
1
2
3
4
5
6
7
8
9
10
11
2
3
4
5
6
7
8
9
10
11
Hours
Hours

As the ICP stabilizes, the % change normalizes as well
Sedated on a fentanyl gtt (100 mcg/hr)
4/13/11: POD 6 Right Eye MAX/MIN/NPI
ICP
MAX
MIN
NPI
10
2.75
2.46
3.9
13
2.74
2.41
4.1
11
2.63
2.26
4.3
8
2.66
2.31
4.1
9
2.59
2.25
4.2
8
2.57
2.23
4.2
11
2.66
2.31
4.1
11
2.63
2.33
4.1
8
2.59
2.25
4.2
10
2.66
2.14
4.5
8
2.68
2.33
4.1
4/13/11: Left Eye MAX/MIN/NPI
ICP
MAX
MIN
NPI
10
3.31
2.91
13
3.12
2.89
11
3.1
2.75
8
3.08
2.77
9
3.22
2.78
8
3.01
2.72
11
3.03
2.79
11
3.16
2.87
8
2.99
2.67
10
3.46
2.93
8
3.41
3.02
3.5
3.4
3.6
3.5
3.7
3.6
3
3.3
3.7
3.5
3.3
RN Exam: Right- 3 and brisk, Left- 4 and Fixed
Pupillometer Exam: Right- 2.6-2.7 and reactive, Left- 2.99-3.5 and Normal
The nurse did notice that the right eye was smaller and more reactive than
the left eye but the left eye was never fixed according to the objective
measurement!

Its Easy!! It’s portable!! It’s user friendly!!

It is a reliable, repetitive, and safe method
that provides detailed and accurate
information regarding pupillary response!

Non invasive

Head injury and at high risk for developing increased
ICP






Acute large hemispheric ischemic stroke
ICH
Post-op craniotomy
Subdural Hematoma
Poor grade SAH with aneurysmal rupture
Pts with pupil checks only for neuro exam testing

With ICP monitor with ICP < 20 mmHg should have
pupils checked with Pupillometer Qshift

ICP readings > 20mmHg should have pupils checked
with Pupillometer hourly and after ICP intervention

Pts in barbiturate coma lost pupillary response to
light- use Pupillometer Q shift

Should be used for a routine pupil measurement
instead of penlight or flashlight

These measurements can help influence the
medical decisions of care!

Detect abnormalities faster and help motivate
interventions.

Start using it early and use the trends!! Don’t
stop taking measurements!

In this case, what could we have done in the
management of our patient?

What would you do next time when your
notice an unchanging trend in low CV or any
other abnormal trend in measurements?





It is time for your routine pupil assessment.
You notice a decline in GCS.
Your pts pupils are now asymmetric.
You notice an overall decline in your pt neuro
status
Your EVD has a poor waveform, you believe it
is not draining correctly or draining CSF

Use of narcotics:
 Fentanyl decreases bilateral pupillary reflex
dilation
 Versed/Ativan: Bilateral reduction of CV

Challenging in agitated or confused pts

Pts with opthalmological disease, periorbital
or scleral edema
Bader, M. K. (2011). Inside the black box: Multimodality monitoring in the neuro
trauma patient. Unpublished manuscript.
Chen J., Gombart Z., Rogers S., Gardiner S., Cecil S., Bullock R. (2011). Pupillary
reactivity as an early indicator of increased intracranial pressure: The introduction
of neurologic pupil index. Surgical Neurology International, 2(1), 82-86.
Fountas, K., Kapsalaki, E., Machinis, T., & Boev, A. (2006). Clinical implications of
quantitative infrared pupillometry in neurosurgical patients. Neurocritical Care,5.
Meeker M, Du R, Bacchetti P, Privitera C, Larson M, Holland M, Manley G. (2005).
Pupil examination: Validity and clinical utility of an automated
pupilometer.Journal of Neuroscience Nursing, 37(1).
Taylor, W., Chen, J., Meltzer, H., Gennarelli, T., Kelbch, C., Knowlton, S., . . . Marshall,
L. (2003). Qualtitative pupillometry, a new technology: Normative data and
prelimary observations in patients with acute head injury. J Neurosurg, 98, 205213.