Management of Pupil Dilation in Concussion

Initial Assessment

Frequently monitor level of arousal and pupillary changes in patients with concussion, as pupil dilation (particularly unilateral) may indicate deterioration and rising intracranial pressure 1
Assess for other signs of neurological deterioration including gradual development of midposition pupils, worsening of motor responses, changes in respiratory patterns, and development of new brainstem signs 1
Monitor for signs of brainstem compression which may accompany pupillary changes, such as bradycardia, irregular breathing patterns, and sudden apnea 1

For patients showing signs of deterioration with pupillary dilation, elevate head of bed to 30° and administer osmotic therapy (first-line intervention) 1
Hypertonic saline is an alternative osmotic agent 1

For patients with suspected occludable angles, pupil dilation should be done with caution as it can precipitate angle closure 2, 3

Continuous monitoring of pupillary size and reactivity, level of consciousness, vital signs, and neurological status is necessary 1
Avoid hyperventilation except in cases of imminent cerebral herniation, and then only for short periods 4