Ventricular Shunt Obstruction/Infection — History and Physical Examination — Clinical Pathway: Emergency, ICU and Inpatient

Ventricular Shunt Obstruction/Infection Clinical Pathway – Emergency, ICU and Inpatient

History and Physical Examination

General

Shunt obstruction presents with variable symptoms of increased intracranial pressure including headache, vomiting and/or altered mental status. A history of symptoms with prior obstruction for the patient can be helpful in assessing risk. The pace of progression varies depending on underlying anatomy and ventricular system compliance; some patients have rapid progression of symptoms requiring emergent management. In patients with recent shunt revision, symptoms of obstruction and infection are similar. Infection typically occurs within 3 months of shunt revision, and fever beyond this timepoint is typically related to another source.

History

Shunt History
  • Type
    • VPeritoneal, Vpleural, VJ, Programmable, Cystoperitoneal
    • Subdural or Subgaleal (not routinely revised)
  • Number
  • Indication for shunt
  • Date of last revision
  • Symptoms with last revision
  • Associated conditions
    • Seizure disorder, CP, Chiari 1 or 2, myelomeningocele (level), trauma, tumor, infection, stroke
Neurologic Symptoms
  • Headache
    • Quality, duration, location, treatment
    • Migraine diagnosis
  • Vomiting
    • Timing, number of/last episode of emesis
  • Neurologic Symptoms
    • Change in level of alertness (what is the patient’s baseline)
    • Increased drowsiness, sleeping
    • Weakness
    • Change in / difficulty of gait
    • Seizures
Trauma
  • Recent head trauma
  • Trauma to shunt
Hydration
  • Oral intake, urine output
  • Risk for hypoglycemia
Infection Risk
  • Revision/placement in the last 3 months
  • Pain, redness, swelling at shunt site, over tubing
  • Fever
  • HA
  • Vomiting
  • Other infectious symptoms that suggest another diagnosis as cause of fever (URI, UTI, very important in myelomeningocele)
  • Sick contacts
Abdominal Complaints
  • Significant sudden increase in abdominal girth
  • Abdominal pain
Medications
  • Home medications
  • Compliance
  • Exposure to other medications, recent change in dose that could explain symptoms

Physical Examination

Vital Signs
  • Cushing’s Triad, HTN, bradycardia, irregular respirations (please note baseline values at last doctor visit and ER visit to trend patient)
  • Bradycardia alone
  • Fever
Mental Status
  • Altered mental status, drowsiness, obtundation, coma
Neurologic Exam
  • Upward gaze paresis
  • Abnormal gait
  • Changes in spasticity
Shunt
  • Swelling, redness, pain at shunt site, over tubing, localized fluid collections along shunt
Abdomen
  • Tenderness, mass
     
General Physical Exam
  • Fontanelle, head circumference, abdominal girth
  • Decreased breath sounds (Pleural shunts)