Burr hole: Difference between revisions
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*Small retractors | *Small retractors | ||
*Drill (manual or air/electric powered) | *Drill (manual or air/electric powered) | ||
**Should have both sharp (penetrator) and dull drill bits '''or''' a drill bit with appropriate "clutch" mechanism | **Should have both sharp (penetrator) and dull drill bits '''or''' a drill bit with appropriate "clutch" mechanism (preferred) | ||
*Blunt hooks | |||
*Electrocautery (Bovie), if available | *Electrocautery (Bovie), if available | ||
*Sterile saline | |||
==Procedure== | ==Procedure<ref name="Wilson" /><ref>MacLellan, K. The occasional burr hole. CJRM 1998;3(4):223-2</ref>== | ||
*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 | |||
*Make ~3cm incision and dissect down to bone with scalpel | |||
*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 (assuming use of "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 | |||
*Once blood flow slows/stops, apply loose dressing. (DO NOT tamponade bleeding) | |||
==Follow-up== | |||
*After procedure, pt should be immediately transferred to facility with appropriate neurosurgical availability. | |||
==Complications== | ==Complications== | ||
*Bleeding | |||
*Infection | |||
*Damage to brain parenchyma | |||
==See Also== | ==See Also== | ||
Revision as of 08:18, 22 July 2015
Background
- Expanding intracranial hematoma is rapidly fatal and requires early therapeutic intervention. Morbidity/mortality significantly increases if treatment delayed more than 1.9 hours.[1]
Indications
- Epidural or subdural hematoma with midline shift on imaging and unequal pupils on exam.[2]
- 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 area at facility without CT availability), very high clinical suspicion may be enough.[2]
- e.g. evidence of severe head trauma and unequal pupils, pt presents awake and talking but rapidly deteriorates in setting of head trauma and unequal pupils, etc.
- In absence of imaging (e.g. in rural area at facility without CT availability), very high clinical suspicion may be enough.[2]
Equipment Needed
- Sterile PPE
- Razor
- Chlorhexidine or betadine
- Scalpel
- Small 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 hooks
- Electrocautery (Bovie), if available
- Sterile saline
Procedure[2][3]
- 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
- Make ~3cm incision and dissect down to bone with scalpel
- 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 (assuming use of "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
- Once blood flow slows/stops, apply loose dressing. (DO NOT tamponade bleeding)
Follow-up
- After procedure, pt should be immediately transferred to facility with appropriate neurosurgical availability.
Complications
- Bleeding
- Infection
- Damage to brain parenchyma
See Also
Epidural hemorrhage Subdural hemorrhage
External Links
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.
- ↑ 2.0 2.1 2.2 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.
- ↑ MacLellan, K. The occasional burr hole. CJRM 1998;3(4):223-2