Blocked CSF Shunt

You are the neurosurgery CT1 called to A&E to see a 44-year-old man who had a ventriculoperitoneal shunt inserted 6 months ago. He is currently drowsy and complaining of a headache and nausea. How would you proceed?

Example answer introduction

I am concerned about a possible shunt blockage leading to symptoms of hydrocephalus and I would attend immediately. I would perform an initial assessment and stabilisation, take a history and perform a focused examination, then put in place an initial management plan and inform my registrar. 

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the CCISP / Advance Life Support algorithms.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

  • Disability - AVPU/GCS, Blood glucose, Pupils

  • Exposure - rashes, systemic signs of shock - expose the whole patient - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, blood glucose, Troponin I, clotting studies, blood and urine cultures if spiking a temperature. 

Focused history​

As he is drowsy I would read the medical notes, speak to nursing staff and any relatives present for further information. 

 

  • Allergies

  • Medications – anti-epileptics, anticoagulants, 

  • Past medical history – history of epilepsy, diabetes

  • Last meal

  • Events leading up to this point – Neck stiffness, pyrexia, pain/discharge around shunt site, difficulty walking, urinary incontinence, blurred vision, seizures, worsening memory

Focussed examination and initial investigations

Full neurological examination

 

  • Cranial nerve examination

  • Peripheral nerve examination

  • Cerebellar examination

 

Abdominal examination

  • Tenderness, guarding, peritonism

 

I would then arrange further investigations following discussion with the neurosurgical registrar;

 

  • CT brain

  • Shunt x-ray series

Example questions to progress the station

Q1 Describe the findings on this CT Brain.

Q2 What are the signs and symptoms of the above condition?

 

Q3 Do you know of any other neurological shunts

Q4 What are the potential complications of neurological shunts

Initial management

  • IV fluids

  • Analgesia

  • Senior review by neurosurgical registrar

  • Keep nil by mouth

  • Prep for theatre

  • Keep patient and any relatives informed 

  • Document, document, document!!!

 Escalation
I would inform the Registrar to review the patient in a timely manner, to ensure my diagnosis and management plan were correct and arrange further imaging, 
This is a true neurosurgical emergency and escalation cannot be delayed. 
Useful Resources

Ventriculoperitoneal shunt complications: A review. Interdisciplinary Neurosurgery

Ventriculoperitoneal shunt block: what are the best predictive clinical indicators?

 
Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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