Unilateral Mydriasis in Helicopter Emergency Medical Services: A Case of Ophthalmic Ipratropium Exposure in Pediatric Asthmatic Cardiac Arrest Prompting Cerebral Herniation Prophylaxis

Abstract

This case report describes the medical management for a 14-year-old female patient who suffered cardiac arrest following an acute asthma exacerbation. During air medical transport, the patient developed unilateral mydriasis, a concerning finding often associated with intracranial pathology such as cerebral herniation. Immediate interventions included the administration of hypertonic saline and targeted ventilation strategies to maintain end-tidal carbon dioxide levels within a therapeutic range. Subsequent diagnostic evaluation, including imaging, revealed no neurologic abnormalities, and the mydriasis resolved spontaneously without complications. Ophthalmic ipratropium exposure was suspected as the underlying cause. This case emphasizes the importance of understanding and recognizing pharmacologic causes, such as muscarinic receptor antagonism, in the differential diagnosis of mydriasis. It also underscores the need for continuous reassessment during transport and the potential for cognitive biases to influence decision-making.