Title: Emergency Department Burr Hole (Submitted by Dr. Christina Powell)<br/>Author: WanTsu Wendy Chang<br/><a href='http://umem.org/profiles/faculty/1322/'>[Click to email author]</a><hr/><p> <span style="font-size:14px;">Your patient presents with a large traumatic subdural hematoma with midline shift and clinical evidence of herniation. Your nearest neurosurgeon is several hours away, <em>what do you do?</em></span></p> <p> <span style="font-size:14px;">Initial resuscitation should follow ATLS. Treatment of intracranial hypertension and herniation includes elevating the head of bed, administering osmotic therapies, optimizing analgesia/sedation, and hyperventilation. If all measures have been exhausted and there is a delay to definitive neurosurgical intervention, an emergency department burr hole may be considered.</span></p> <p> <span style="font-size:14px;"><strong><u>Indications</u>:</strong></span></p> <ul> <li> <span style="font-size:14px;">GCS < 8, dilated and nonreactive pupil(s), posturing suggestive of uncal or transtentorial herniation </span></li> <li> <span style="font-size:14px;">Radiographic evidence of an extra-axial (subdural/epidural) hematoma causing midline shift and brainstem compression</span></li> <li> <span style="font-size:14px;">Lack of timely neurosurgical intervention</span></li> <li> <span style="font-size:14px;">Procedure will not delay transfer to definitive care</span></li> </ul> <p> <span style="font-size:14px;"><strong><u>Contraindications</u>:</strong></span></p> <ul> <li> <span style="font-size:14px;">Neurosurgical intervention available within reasonable time frame</span></li> <li> <span style="font-size:14px;">Skull fracture at site of planned burr hole</span></li> </ul> <p> <span style="font-size:14px;"><strong><u>Equipment</u>:</strong></span></p> <ul> <li> <span style="font-size:14px;">Razor</span></li> <li> <span style="font-size:14px;">Surgical marker</span></li> <li> <span style="font-size:14px;">Sterile prep and drape</span></li> <li> <span style="font-size:14px;">Syringe, needle, lidocaine</span></li> <li> <span style="font-size:14px;">Scalpel, forceps, retractor, sharp hook, scissors</span></li> <li> <span style="font-size:14px;">Hand drill, hex wrench, drill bit with guard</span></li> <li> <span style="font-size:14px;">Sterile saline, gauze, dressing</span></li> </ul> <p> <span style="font-size:14px;"><strong><u>Transtemporal Approach</u>:</strong></span></p> <ul> <li> <span style="font-size:14px;">Measure skull thickness on CT for depth of drill guard.</span></li> <li> <span style="font-size:14px;">Position patient supine and elevate the ipsilateral shoulder with a shoulder roll. Utilize tape or have assistant hold the head in place. </span></li> <li> <span style="font-size:14px;">Shave the hair.</span></li> <li> <span style="font-size:14px;">Mark the point 2 cm superior and 2 cm anterior to the tragus.</span></li> <li> <span style="font-size:14px;">Sterile prep and drape.</span></li> <li> <span style="font-size:14px;">Inject local anesthetic and then make a 3 cm vertical skin incision down to the periosteum. Dissect and use a retractor to expose the skull.</span></li> <li> <span style="font-size:14px;">Drill with steady pressure perpendicular to the skull. Irrigate with sterile saline to remove bone fragments.</span></li> <li> <span style="font-size:14px;">Once the skull is penetrated:</span> <ul> <li> <span style="font-size:14px;">If an epidural hematoma, blood should be released. Can use sterile saline to facilitate drainage of clotted blood.</span></li> <li> <span style="font-size:14px;">If a subdural hematoma, use a sharp hook to tent the dura and make a small cruciate incision.</span></li> </ul> </li> <li> <span style="font-size:14px;">Place loose sterile dressing.</span></li> <li> <span style="font-size:14px;">Transfer to definitive care.</span></li> </ul> <p> <span style="font-size:14px;"><strong><u>Additional Points</u>:</strong></span></p> <ul> <li> <span style="font-size:14px;">Neurosurgery consultation before performing this procedure is recommended. </span></li> <li> <span style="font-size:14px;">Antibiotic prophylaxis with gram-positive coverage is recommended.</span></li> <li> <span style="font-size:14px;">In extenuating circumstances, this may be considered without CT confirmation of the location of the extra-axial hematoma. However, there is risk of a negative exploratory burr hole due to a hematoma not in the temporal location or due to a <a href="https://em.umaryland.edu/educational_pearls/3061/">false localizing sign</a>.</span></li> </ul> <fieldset><legend>References</legend>
<ul> <li> Wilson MH, Wise D, Davies G, Lockey D. Emergency burr holes: “How to do it.” <em>Scand J Trauma Resusc Emerg Med</em>. 2012 Apr 2;20:24.</li> <li> Donovan DJ, Moquin RR, Ecklund JM. Cranial burr holes and emergency craniotomy: review of indications and technique. <em>Mil Med</em>. 2006;171(1):12-9.</li> <li> Hsu E, Buffin N. Unlocking Common ED Procedures – Crackin’ the Cranium: A Review of Cranial Burr Hole Decompression. emDOCs.net http://www.emdocs.net/unlocking-common-ed-procedures-crackin-the-cranium-a-review-of-cranial-burr-hole-decompression/ Published April 9, 2020. Accessed October 13, 2021.</li> </ul> <p style="text-align: center;"> <em><strong>Follow us on Twitter @christinap0well @EM_NCC</strong></em></p> </fieldset>