Pediatric emergency medicine trisk 4654 4654

FIGURE 135.5 Burr-hole puncture The child with complete obstruction of the proximal catheter does not obtain relief of symptoms after a shunt tap because the obstruction prevents adequate aspiration of fluid from the ventricles These children usually respond temporarily to medical management that decreases their ICP; however, it should be stressed that restoration of shunt integrity and function is the permanent treatment of shunt obstruction In the emergent situation, this treatment includes the administration of 3% normal saline (5 mL/kg bolus) Further therapy is with acetazolamide (Diamox) 30 to 80 mg/kg/day and Decadron mg/kg/day and hyperventilation in the unstable patient The following procedures are not commonly performed in the ED, and even more rarely performed by a clinician other than a neurosurgeon If the child is experiencing life-threatening symptoms from proximal obstruction, is unable to undergo immediate surgical repair, and is unresponsive to medical management, a burr-hole puncture procedure may be performed ( Fig 135.5 ) This should be performed only in dire circumstances, as the procedure carries with it lifethreatening risks such as disruption of intraparenchymal vessels and tissue By nature of the procedure itself, the proximal shunt catheter is torn and urgent revision is therefore mandatory The burr hole is best identified by direct palpation and confirmation with the skull radiographs For example, some reservoirs are not always located over the burr hole A 3½-in spinal needle is