Burr hole: Difference between revisions
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== | ==Overview== | ||
*Expanding intracranial hematoma is rapidly fatal and requires early therapeutic intervention. Morbidity/mortality significantly increases if treatment delayed more than 1.9 hours.<ref>Mendelow AD, Karmi MZ, Paul KS, Fuller GA, Gillingham FJ. Extradural haematoma: effect of delayed treatment. British Medical Journal. 1979;1(6173):1240-1242.</ref> | *Expanding intracranial hematoma is rapidly fatal and requires early therapeutic intervention. Morbidity/mortality significantly increases if treatment delayed more than 1.9 hours.<ref>Mendelow AD, Karmi MZ, Paul KS, Fuller GA, Gillingham FJ. Extradural haematoma: effect of delayed treatment. British Medical Journal. 1979;1(6173):1240-1242.</ref> Other studies have indicated poor prognosis if treatment delayed beyond 70 minutes.<ref name="Smith">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.</ref> | ||
*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== | ==Indications== | ||
| Line 11: | Line 12: | ||
*Neurosurgery available in reasonable timeframe | *Neurosurgery available in reasonable timeframe | ||
*Lack of imaging-confirmed epidural or subdural hematoma | *Lack of imaging-confirmed epidural or subdural hematoma | ||
**In absence of imaging (e.g. in rural area at facility without CT availability), very high clinical suspicion may be enough.<ref name="Wilson" /> | **In absence of imaging (e.g. in rural/wilderness area at facility without CT availability), very high clinical suspicion may be enough.<ref name="Wilson" /> | ||
***e.g. evidence of severe head trauma and unequal pupils, | ***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. | ||
==Considerations<ref>Hacking C and Elgendy A. Uncal herniation. Radiopaedia. http://radiopaedia.org/articles/uncal-herniation-1.</ref>== | |||
*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== | ==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 | *Sterile PPE | ||
*Chlorhexidine or betadine | *Chlorhexidine or betadine | ||
* | *Sterile saline | ||
*Electrocautery (Bovie), if available | *Electrocautery (Bovie), if available | ||
==Procedure<ref name="Wilson" /><ref>MacLellan, K. The occasional burr hole. CJRM 1998;3(4):223-2</ref>== | ==Procedure<ref name="Wilson" /><ref>MacLellan, K. The occasional burr hole. CJRM 1998;3(4):223-2</ref>== | ||
[[File:burr hole.JPG|thumb]] | |||
*Place patient supine | *Place patient supine | ||
*Select optimal site based on location of hemorrhage on CT (if unsure, use temporal site) | *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 | **'''Temporal''' - 2 finger-breadths above and 2 finger-breadths forward of the auditory canal | ||
**'''Parietal''' - over parietal eminence | **'''Parietal''' - over parietal eminence | ||
**'''Frontal''' - 10 cm above eye in mid-pupillary line | **'''Frontal''' - 10 cm above eye in mid-pupillary line (about 3 cm from sagittal suture) | ||
*Shave scalp widely over selected site | *Shave scalp widely over selected site | ||
*Cleanse skin with | *Cleanse skin with chlorhexadine or betadine and drape in sterile fashion | ||
*Make ~3cm incision and dissect down to bone with scalpel | *Set drill depth based on thickness of skull (as measured on CT) | ||
*Make ~3cm incision and dissect down to bone with scalpel (control bleeding with direct pressure or electrocautery) | |||
*Dissect periosteum off bone with scalpel | *Dissect periosteum off bone with scalpel | ||
*Apply retractors to maintain field | *Apply retractors to maintain field | ||
*Apply drill perpendicular to skull and begin drilling while applying firm pressure | *Apply drill perpendicular to skull and begin drilling while applying firm pressure | ||
**Have assistant apply gentle saline wash to drilling site | **Have assistant apply gentle saline wash to drilling site | ||
*Continue drilling until loss of resistance felt '''or''' drill bit stops spinning ( | *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 | *Use hooks to remove any remaining bone fragments | ||
**Preserve skull fragments in container of sterile saline | |||
*If subdural hematoma, elevate dura with sharp hook and make careful incision with scalpel | *If subdural hematoma, elevate dura with sharp hook and make careful incision with scalpel | ||
*Allow blood to drain freely | *Allow blood to drain freely (gentle suction may be used, but DO NOT suction brain tissue) | ||
*Once blood flow slows/stops, apply loose dressing | *Once blood flow slows/stops, apply loose dressing (DO NOT tamponade bleeding) | ||
== | ==Disposition== | ||
* | *Provide [[ceftriaxone]] IV for antibiotic prophylaxis after procedure | ||
*Transfer immediately to facility with appropriate ICU and neurosurgical capability | |||
==Complications== | ==Complications== | ||
| Line 54: | Line 66: | ||
==See Also== | ==See Also== | ||
[[Epidural hemorrhage]] | *[[Epidural hemorrhage]] | ||
[[Subdural hemorrhage]] | *[[Subdural hemorrhage]] | ||
==External Links== | ==External Links== | ||
===Videos=== | |||
{{#widget:YouTube|id=QeDQZoeg0RA}} | |||
==References== | ==References== | ||
| Line 65: | Line 79: | ||
[[Category:Procedures]] | [[Category:Procedures]] | ||
[[Category:Critical Care]] | [[Category:Critical Care]] | ||
[[Category: | [[Category:Neurology]] | ||
Latest revision as of 01:18, 29 June 2021
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 (about 3 cm from sagittal suture)
- Shave scalp widely over selected site
- Cleanse skin with chlorhexadine or betadine and drape in sterile fashion
- Set drill depth based on thickness of skull (as measured on CT)
- 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
- Preserve skull fragments in container of sterile saline
- 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)
Disposition
- Provide ceftriaxone IV for antibiotic prophylaxis after procedure
- Transfer immediately to facility with appropriate ICU and neurosurgical capability
Complications
- Bleeding
- Infection
- Damage to brain parenchyma
See Also
External Links
Videos
{{#widget:YouTube|id=QeDQZoeg0RA}}
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