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 hemorrhage|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.</ref>==
==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]]
*Attempt informed consent from surrogate decision maker, if possible
 
*Medically optimize the patient (intubated, normotensive, c-spine precautions, +/- mannitol or hypertonic saline in consultation with a neurosurgeon)
*Place patient supine
*Place the patient in the supine position
*Select optimal site based on location of hemorrhage on CT (if unsure, use temporal site)
*Ensure indications are appropriate.
**'''Temporal''' - 2 finger-breadths above and 2 finger-breadths forward of the auditory canal
*Review position of the hematoma on Head CT
**'''Parietal''' - over parietal eminence
*Using a marking pen, mark a 3cm line for the incision
**'''Frontal''' - 10 cm above eye in mid-pupillary line (about 3 cm from sagittal suture)
*Cleanse the area appropriately (chlorhexidine/betadine)
*Shave scalp widely over selected site
*Drape in sterile fashion
*Cleanse skin with chlorhexadine or betadine and drape in sterile fashion
*Using knife, make a small incision down to the bone
*Set drill depth based on thickness of skull (as measured on CT)
**Control bleeding with direct pressure
*Make ~3cm incision and dissect down to bone with scalpel (control bleeding with direct pressure or electrocautery)
*Using a knife, push the periosteum aside
*Dissect periosteum off bone with scalpel
*Insert a self-retaining retractor
*Apply retractors to maintain field
*Use hand drill with firm pressure, surface of drill bit parallel to bone surface (drill perpendicular to bone)
*Apply drill perpendicular to skull and begin drilling while applying firm pressure
**If available, have an assistant hold the head still from beneath the drape
**Have assistant apply gentle saline wash to drilling site
**Also consider an additional assistant applying sterile saline to the drill site while creating burr hole
*Continue drilling until loss of resistance felt '''or''' drill bit stops spinning (when using "clutch"-type drill bit)
*Slow drill speed once at the inner table of the skull; remove drill
*Use hooks to remove any remaining bone fragments
*Remove any remaining bony fragments
**Preserve skull fragments in container of sterile saline
*Drain visible (flowing) extradural blood
*If subdural hematoma, elevate dura with sharp hook and make careful incision with scalpel
*Subdural blood may be evacuated following dural puncture (do not perform unless trained and neurosurgical consultant advises)
*Allow blood to drain freely (gentle suction may be used, but DO NOT suction brain tissue)
**This is technically more difficult, as subdural blood is more likely to clot and be difficult to evauate
*Once blood flow slows/stops, apply loose dressing (DO NOT tamponade bleeding)
*Transfer patient to facility with neurosurgical capabilities
 
==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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