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Burr hole
From WikEM
Contents
Overview
- Expanding intracranial hematoma is rapidly fatal and requires early therapeutic intervention. Morbidity/mortality significantly increases if treatment delayed more than 1.9 hours.[1] Other studies have indicated poor prognosis if treatment delayed beyond 70 minutes.[2]
- This procedure is rarely performed by emergency physicians, and every effort should be made to discuss the patient and plan for procedure with a neurosurgeon prior to intervention.
Indications
- Epidural or subdural hematoma with midline shift on imaging and unequal pupils on exam.[3]
- GCS <8
- Anticipated extended time to assessment/treatment by neurosurgeon.
Contraindications
- GCS >8
- Neurosurgery available in reasonable timeframe
- Lack of imaging-confirmed epidural or subdural hematoma
- In absence of imaging (e.g. in rural/wilderness area at facility without CT availability), very high clinical suspicion may be enough.[3]
- e.g. evidence of severe head trauma and unequal pupils, patient presents awake and talking but rapidly deteriorates in setting of head trauma and unequal pupils, etc.
- In absence of imaging (e.g. in rural/wilderness area at facility without CT availability), very high clinical suspicion may be enough.[3]
Considerations[4]
- Unilateral transtentorial herniation (more common) usually causes ipsilateral fixed and dilated pupil if it localizes
- Bilateral transtentorial herniation (less common) due to extensive mass effect or severe trauma
Equipment Needed
- Cranial access kit
- Razor
- Scalpel
- Self-retaining retractors
- Drill (manual or air/electric powered)
- Should have both sharp (penetrator) and dull drill bits or a drill bit with appropriate "clutch" mechanism (preferred)
- Blunt and sharp hooks
- Hemostats and forceps
- Sterile PPE
- Chlorhexidine or betadine
- Sterile saline
- Electrocautery (Bovie), if available
Procedure[3][5]
- Place patient supine
- Select optimal site based on location of hemorrhage on CT (if unsure, use temporal site)
- Temporal - 2 finger-breadths above and 2 finger-breadths forward of the auditory canal
- Parietal - over parietal eminence
- Frontal - 10 cm above eye in mid-pupillary line
- Shave scalp widely over selected site
- Cleanse skin with chlorhexidine or betadine and drape in sterile fashion
- Make ~3cm incision and dissect down to bone with scalpel (control bleeding with direct pressure or electrocautery)
- Dissect periosteum off bone with scalpel
- Apply retractors to maintain field
- Apply drill perpendicular to skull and begin drilling while applying firm pressure
- Have assistant apply gentle saline wash to drilling site
- Continue drilling until loss of resistance felt or drill bit stops spinning (when using "clutch"-type drill bit)
- Use hooks to remove any remaining bone fragments
- If subdural hematoma, elevate dura with sharp hook and make careful incision with scalpel
- Allow blood to drain freely (gentle suction may be used, but DO NOT suction brain tissue)
- Once blood flow slows/stops, apply loose dressing. (DO NOT tamponade bleeding)
Follow-up
- After procedure, patient should be immediately transferred to facility with appropriate neurosurgical availability.
Complications
- Bleeding
- Infection
- Damage to brain parenchyma
See Also
References
- ↑ Mendelow AD, Karmi MZ, Paul KS, Fuller GA, Gillingham FJ. Extradural haematoma: effect of delayed treatment. British Medical Journal. 1979;1(6173):1240-1242.
- ↑ Smith SW, Clark M, Nelson J, et al. Emergency department skull trephination for epidural hematoma in patients who are awake but deteriorate rapidly. J Emerg Med. 2010 Sep;39(3):377-83.
- ↑ 3.0 3.1 3.2 Wilson MH, Wise D, Davies G, Lockey D. Emergency burr holes: “How to do it.” Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2012;20:24. doi:10.1186/1757-7241-20-24.
- ↑ Hacking C and Elgendy A. Uncal herniation. Radiopaedia. http://radiopaedia.org/articles/uncal-herniation-1.
- ↑ MacLellan, K. The occasional burr hole. CJRM 1998;3(4):223-2
