VP Shunt Algo v1

  • Branch A Patient presents with VP shunt (if patient presents with VP shunt and a fever start on branch B)
    • Is patient ill-appearing or obtunded and/or vs concerning for Cushings Triad?
      • Yes
        • STAT NS Consult, STAT head CT, NPO, STAT IV access – Consider hypertonic saline/Mannitol
      • No
        • Problem potentially related to VP shunt?
          • No
            • Treat per chief complaint, No consult needed unless indicated for any other reasons.
          • Yes
            • CR Monitor at least first 30 min, VS Q60 min, vent check MRI, conslut NS (not stat)
              • Hx/PE Suggestive of Shunt Disconnect?
                • Yes
                  • Shunt series
                    • Is imaging (MRI or shunt series) abnormal?
                    • Yes
                      • Discuss result with NS, possibly for additional imaging, admission, surgery
                        • Admission to NS or OR
                    • No
                      • If still clinical concern regarding possible shunt malfunction, discuss further with NS attending.
                        • Meets D/C criteria?
                          • No
                            • Admission to NS or Gen Peds
                          • Yes
                            • D/C with PCP follow-up within 24 hours
  • Branch B Patient presents with VP shunt and a fever (if no fever start on branch A)
    • Is patient ill-appearing or obtunded and/or vs concerning for Cushings Triad
      • Yes
        • STAT NS Consult, STAT head CT, NPO STAT IV access – Consider hypertonic saline/mannitol
      • No
        • VP shunt placed or revised < 3 months ago?
          • No
            • Abdominal pain or tenderness on abdominal examination?
              • No
                • Go to branch A and begin near the top at “Problem potentially related to VP shunt?”
              • Yes
                • NS consult, IV insertion. Labs: abdominal ultrasound, CBC, differential, blood culture, consider vent check MRI
                  • Is imaging or are labs abnormal?
                    • Yes
                      • Discuss result with NS, possibility for additional imaging, admission, surgery
                        • Admission to NS or OR
                    • No
                      • If still clinical concern regarding possible shunt malfunction, discuss further with NS attending
                        • Meets D/C criteria?
                          • No
                            • Admission to NS or Gen Peds
                          • Yes
                            • D/C with PCP follow-up within 24 hours
          • Yes
            • NS consult, IV insertion. Labs: CBC, differential blood culture, T&S vent check MRI
              • (copy paste) Is imaging or are labs abnormal?
                • Yes
                  • Discuss result with NS, possibility for additional imaging, admission, surgery
                    • Admission to NS or OR
                • No
                  • If still clinical concern regarding possible shunt malfunction, discuss further with NS attending
                    • Meets D/C criteria?
                      • No
                        • Admission to NS or Gen Peds
                      • Yes
                        • D/C with PCP follow-up within 24 hours

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