EMS is bringing you a child with a VP shunt, port-a-cath, trached on a vent, seizing, hypotensive, and now desaturating – ETA – 3 minutes. Are you ready?
Medicine is evolving. As technology advances, we need to meet the challenge of taking care of our patients who have come to rely on this technology for their basic needs.  Before we go further, remember to assess the parent and the child as a unit.  The caregiver who is usually the parent, is a rich source of knowledge about the child’s particular condition and past experience.  Take them seriously, and be on the lookout for caregiver burnout.
Tracheostomy Troubles
4-month-old baby boy born full term with Pierre Robin Sequence, febrile, not eating anything, now with breathing difficulty. Place on trach collar oxygen, suction those secretions; flush with small amounts of saline, and repeat.
Any child symptomatic with a trach? Remember to monitor for hypoxia and bradycardia.
Tracheostomy indications: obstruction, primary respiratory compromise, or a neurologic disorder.  The obstruction may be a tumor, post-infectious, or addressing a congenital anomaly.  Children may have bronchopulmonary dysplasia, a restrictive lung disease such as scoliosis. A wide array of neurologic problems can result in a child’s having a trach, such as cerebral palsy, TBI, or spinal muscular atrophy.
Early complications of trachs especially in the first few months – include bleeding, pneumomediastinum, accidental decanulation, wound breakdown, and subcutaneous emphysema. The most common later complications include infection and granuloma formation. Tracheo-esophageal fistulas and trachea-innominate fistulas are thankfully very rare.
VP Shunt Shudderings
11-year-old girl with a history of prematurity, intraventricular hemorrhage, and subsequent flaccid paralysis with neurogenic bladder. She is brought in by her mother because of constipation and “not acting her usual self”.  She is afebrile, abdomen is soft, full of stool.
The most common shunt is the ventriculoperitoneal shunt, originating in a lateral ventricle and tracking subcutaneously down the neck and chest until the distal end enters and coils in the peritoneal space.  Less common types include ventriculoatrial, ventriculopleural, ventriculocisternal, ventriculo-vesicular (to gall bladder) and the lumbo-peritoneal, usually reserved for spina bifida.
The common denominator: hydrocephalus.  The most common causes are tumor, congenital anomalies, hemorrhage, or post-infectious obstructions.
The two most common complications of VP shunts are malfunction (due to obstruction, fracture, or kinking) or infection.  The slit-ventricle syndrome results from overdrainage, causing headaches and ataxia and the slit-ventricle syndrome.  An abdominal pseudocyst forms when cells floating in the peritoneal cavity aggregate on the distal tip of the VP shunt, forming a biofilm that fills with CSF.  VP shunts, like any foreign body, can migrate and erode through intestines and skin.
Classically in severe hydrocephalus an infant or toddler will have sun-setting eyes – the irises look like a setting sun against the prominent bulbar conjunctiva.  However, the presentation is usually much more subtle; if the child just feels off or if the parent tells you he is not acting right, this is a shunt malfunction until proven otherwise.
Garton et al. in the Journal of Neurosurgery followed 344 children with shunts, and found that in the first six months after a shunt is placed, the presence of nausea or vomiting carried a positive LR pf 10.4 for shunt malfunction.  Irritability conveyed a positive LR of 9.8 for shunt malfunction. Decreased LOC was 100% predictive.
Most shunt infections occur within a few weeks after placement. 90% of infections occur within the first 9 months. Fever is only 60% sensitive, but CRP is 95% specific.
If the child has severe mental status changes, hypertension, and/or bradycardia, tap the shunt emergently.
Head of the bed is 30 degrees; sterile fas