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EVD Tips
#11
I posted the long response above. Senior resident in a midwestern program.

We usually log 20-30 EVDs in our intern year, and a similar number of ICP monitors, then rate slows down as we progress through the years to allow younger residents get the experience. I've placed only 1 EVD this academic year for example. I have 80 EVD/ICP monitors in my case log by now, but it doesn't really show how many of those are EVDs vs ICP monitors.

As someone mentioned above, at my program, we are biased towards ICP monitors rather than EVDs for the initial management of TBI. So those EVDs we place are usually for hydrocephalus rather than ICP management, except for those TBI patients who failed everything else including craniectomy, and who have decent sized ventricles. We do place EVDs in tiny ventricles in such patients sometimes, but in those cases, I would recommend using some sort navigation at bedside or in OR as it is not easy to hit those slit ventricles surrounded by edematous brain that bleeds easily from multiple passes. 99.9% of our EVDs are freehand at bedside though, so paying attention to the landmarks and the anatomy are enough to get you on the right track.

As with everything, it needs practice, and constant feedback from your post-procedure CT scans to improve your placements. Good thing though, it doesn't need a ton of EVDs to master it, at least for the frontal EVDs.

For posterior parietal EVDs, you can use Frazier point, but the trajectory and depth are not straightforward or universal, you will have to do some adjustments from patient to patient based on imaging. Those aren't common EVDs for our bread and butter TBI, GSW, and stroke patients.

An important tip that we sometimes forget in emergencies is to check coags, labs, platelets, history of antiplatelets/anticoagulation, last dose of DVT prophylaxis, etc. Sometimes you still have to do the procedure anyways if patient is herniating, but at least can give family a heads up that there is high risk of bleeding if they are on antiplatelets or anticoagulation.
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#12
What's the rationale in offering a craniectomy, a fairly morbid surgery, prior to EVD in a severe TBI patient for ICP management?
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#13
Sometimes an EVD just won't cut it. It is great for patients that have hydrocephalus or just need ICP monitoring because of a compromised exam, but the reality is an EVD isn't going to fix 10 mm of midline shift. In fact, it might worsen it.
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#14
Echo the sentiment above about the importance of landmarks. The most common reason I see people miss EVDs is that they drill too lateral (either marking too lateral or letting the drill slide lateral from a good starting spot.
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