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> 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==
Rapidly deteriorating patients (GCS < 8) with imaging evidence of epidural hematoma causing midline shift, unequal pupils, for whom timely intervention by neurosurgery is not possible. Every attempt should be made to discuss the patient and plan for procedure with a neurosurgeon prior to intervention.
*[[Epidural hemorrhage|Epidural]] or [[Subdural hemorrhage|subdural]] hematoma with midline shift on imaging and unequal pupils on exam.<ref name="Wilson">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.</ref>
[[File:Epidural_Hematoma.jpg|thumb|Epidural hematoma without significant midline shift]]
*GCS <8
*Anticipated extended time to assessment/treatment by neurosurgeon.


==Contraindications==
==Contraindications==
*GCS > 8
*GCS >8
*No neuroimaging
*Neurosurgery available in reasonable timeframe
*Neurosurgical intervention available within a timely manner
*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.<ref name="Wilson" />
***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==
Many items contained in pre-packaged Cranial Access Kit
*Cranial access kit
*Knife
**Razor
*Self-retaining retractor
**Scalpel
*Drill
**Self-retaining retractors
*Bipolar cautery (if available*
**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<ref>Wilson MH, Wise D, Davies G, Lockey D. Emergency burr holes: "How to do it". Scand J Trauma Resusc Emerg Med. 2012; 20: 24.==
==Procedure<ref name="Wilson" /><ref>MacLellan, K. The occasional burr hole. CJRM 1998;3(4):223-2</ref>==
*Do not delay transfer if timely neurosurgical intervention is available
[[File:burr hole.JPG|thumb]]
*Medically optimize the patient (intubated, normotensive, c-spine precautions, +/- mannitol or hypertonic saline in consultation with a neurosurgeon)
 
*Place the patient in the supine position
*Place patient supine
*Ensure indications are appropriate.
*Select optimal site based on location of hemorrhage on CT (if unsure, use temporal site)
*Review position of the hematoma on Head CT
**'''Temporal''' - 2 finger-breadths above and 2 finger-breadths forward of the auditory canal
*Using a marking pen, mark a 3cm line for the incision
**'''Parietal''' - over parietal eminence
*Cleanse the area appropriately (chlorhexidine/betadine)
**'''Frontal''' - 10 cm above eye in mid-pupillary line (about 3 cm from sagittal suture)
*Drape in sterile fashion
*Shave scalp widely over selected site
*Using knife, make a small incision down to the bone
*Cleanse skin with chlorhexadine or betadine and drape in sterile fashion
**Control bleeding with direct pressure
*Set drill depth based on thickness of skull (as measured on CT)
*Using a knife, push the periosteum aside
*Make ~3cm incision and dissect down to bone with scalpel (control bleeding with direct pressure or electrocautery)
*Insert a self-retaining retractor
*Dissect periosteum off bone with scalpel
*Use hand drill with firm pressure, surface of drill bit parallel to bone surface (drill perpendicular to bone)
*Apply retractors to maintain field
**If available, have an assistant hold the head still from beneath the drape
*Apply drill perpendicular to skull and begin drilling while applying firm pressure
**Also consider an additional assistant applying sterile saline to the drill site while creating burr hole
**Have assistant apply gentle saline wash to drilling site
*Slow drill speed once at the inner table of the skull; remove drill
*Continue drilling until loss of resistance felt '''or''' drill bit stops spinning (when using "clutch"-type drill bit)
*Remove any remaining bony fragments
*Use hooks to remove any remaining bone fragments
*Drain visible (flowing) extradural blood
**Preserve skull fragments in container of sterile saline
*Subdural blood may be evacuated following dural puncture (do not perform unless trained and neurosurgical consultant advises)
*If subdural hematoma, elevate dura with sharp hook and make careful incision with scalpel
**This is technically more difficult, as subdural blood is more likely to clot and be difficult to evauate
*Allow blood to drain freely (gentle suction may be used, but DO NOT suction brain tissue)
*Transfer patient to facility with neurosurgical capabilities
*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==
*Procedure failure (incorrect position, equipment malfunction, etc.)
*Bleeding
*Infection
*Damage to brain parenchyma
*Damage to brain parenchyma
*Intracranial infection
*Damage to subdural contents
*Continued bleeding


==See Also==
==See Also==
[[Epidural hemorrhage]]
*[[Epidural hemorrhage]]
*[[Subdural hemorrhage]]


==External Links==
==External Links==
[http://resus.me/burr-holes-by-emergency-physicians/ Resus.Me Discussion of Burr Holes by Emergency Physicians]
 
===Videos===
{{#widget:YouTube|id=QeDQZoeg0RA}}


==References==
==References==
*Smith SW, Clark M, Nelson J, Heegaard W, Lufkin KC, Ruiz E. Emergency department skull trephination for epidural hematoma in patients who are awake but deteriorate rapidly. J Emerg Med. 2010 Sep;39(3):377-83. doi: 10.1016/j.jemermed.2009.04.062. Epub 2009 Jun 17.
<references/>
<references/>


[[Category:Procedures]]
[[Category:Procedures]]
[[Category:Critical Care]]
[[Category:Critical Care]]
[[Category:Neuro]]
[[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.

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]

Burr hole.JPG
  • 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

  1. ↑ Mendelow AD, Karmi MZ, Paul KS, Fuller GA, Gillingham FJ. Extradural haematoma: effect of delayed treatment. British Medical Journal. 1979;1(6173):1240-1242.
  2. ↑ 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. ↑ 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.
  4. ↑ Hacking C and Elgendy A. Uncal herniation. Radiopaedia. http://radiopaedia.org/articles/uncal-herniation-1.
  5. ↑ MacLellan, K. The occasional burr hole. CJRM 1998;3(4):223-2
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