Sinai St. Lukes West) and Nicholas Buffin, MD (EM Resident Physician, Mt. Please consult the latest official manual style if you have any questions regarding the format accuracy. We have learned a few practical things at our institution that I would like to share: It is an unnecessary waste of time and the patient should proceed directly to the Operating Room. Separate multiple email address with semi-colons (up to 5). Your own risks may vary according to your age, your general health, and the reason for your procedure. 2022. With widespread availability of quickly accessible CT scanning, exploratory burr holes are infre- quently indicated. In 100 trauma patients An immediate, sudden rupture might cause blood to build up very quickly. This procedure may be performed by trained Emergency Physicians if a Neurosurgeon has been consulted and is not immediately available. Confirm skull thickness on CT as seen below in figure 1. Irrigate the area. He or she then opens the dura and drains any excess fluid. The bony vault of the skull is fairly thick, approximately 5 mm in thickness, and shows considerable individual and regional variation. Mjovsk, M., Netuka, D., Bene, V. & Kucera, P. Burr-hole evacuation of chronic subdural hematoma: Biophysically and evidence-based technique improvement. Diagnostic burr hole exploration and evacuation of an extra-axial hematoma can be a lifesaving measure. Postprocedural CT scanning should not be performed if definitive management by a Neurosurgeon is available. CT-proven intracranial hematoma epidural/subdural (ICH) with midline shift, 2. Most operation requires to make several burr holes to allow surgeons to access a wider area of the brain 1. Measure the skull thickness on CT to set stopper depth on the Integra skull trephination kit with adjustable stopper. When expanded, this should create a clear path directly down to the bone. Perform a time out to ensure that everyone involved is aware of the patient identity, the plan for the coming procedure, why the procedure is being performed, and the side on which the procedure will occur. If unsuccessful after three attempts, place the parenchymal monitor or a subarachnoid bolt. Our hospital had never even had a skull trephination kit before. The general steps include 4: After this operation, youll move to the recovery place and stay in the hospital for 1 or 2 days.
Authors: Edmund Hsu, MD (EM Resident Physician, Mt. 6) If no blood is noted to extravasate, continue to work towards transferring the patient to more definitive care. The placement of a temporal burr hole on the side of the mydriatic pupil to decompress an epidural or subdural hematoma can be lifesaving. The skull shows four separate holes made by trephination that had begun to heal, indicating that the patient survived the procedure. In a trauma patient, the clinical triad of altered mental status, unilateral pupillary dilatation with loss of light reflex, and contralateral hemiparesis is most often due to upper brainstem compression by uncal transtentorial herniation which, in the majority of trauma cases, is due to an extraaxial intracranial hematoma.
positive peritoneal lavage +hemodynamic instability) where there is not time for a brain CT. Inject local anesthetic and then make a 4-cm vertical skin incision down to the periosteum at a point 2 cm superior and 2 cm anterior to the tragus. Acute subdural hematoma: progress in definition, clinical pathology, and therapy. Indications in E/R (rare): patient dying of rapid transtentorial herniation or brainstem compression that does not improve or stabilize with mannitol and hyperventilation
Percentages of epidural hematomas by anatomic location. Once through, if the ICH was epidural you should see blood coming from the burr hole as seen below in figure 2. The middle meningeal artery is a branch of the maxillary artery and enters the cranium via the foramen spinosum. Emergency Twist Drill Trephination. These conditions include acute and chronic subdural hematoma, epidural hematoma,hydrocephalus, removing abscess around the meninges, removing a blood clot, removing a brain tumor, or any foreign object, relieving pressure from the brain, etc. Identify the site to make the burr hole. Burr hole evacuation in a trauma setting should be considered only in the presence of rapid neurological deterioration with evidence of herniation and brainstem compression and the unavailability of a Neurosurgeon to perform the procedure. I thought he had no chance of survival, let alone recovery. 4). Check out our new downloadable procedure card with QR code link to the article. Controversial. The frontal burr hole can be used to drain an intracranial hematoma or to perform a ventriculostomy. This should include intubation if GCS is less than 8. This is when blood slowly builds up under the dura layerafter a mild head injury. The surgeon will make a cut (incision) in your scalp. Burr holes are used to help relieve pressure on the brain when fluid, such as blood, builds up and starts to press on brain tissue. Every effort should be made to discuss with a neurosurgeon about the patient and plan for procedure prior to intervention; however planning should not delay emergent intervention. Otherwise, the available Emergency Physician with the most skill and experience in performing this technique should be the one to place the burr hole.
The cause of death is usually a result of an expanding intracranial hemorrhage, extensive basilar skull fractures with associated injury to the venous sinuses, intracranial carotid artery lacerations, and/or major cortical blood vessel lacerations. 1. Place the burr bit into the hole in the skull. (required - use a semicolon to separate multiple addresses). If required, it is possible to use a pediatric suction catheter (not displayed above) to remove the blood from the epidural space. Neurosurgery. Turn the head to the contralateral side if the cervical spine has been cleared. Other sources of epidural hematomas include a torn venous sinus or an injury to the carotid artery before it enters the intracranial dural mater. Remember that burr hole evacuation cannot correct the bleeding point. It is possible to run sterile saline onto the skull to both remove debris and to keep the friction heat to a minimum.
The neurological examination should include pupillary size and reaction, extraocular muscle function, and motor movements of the extremities. Superior view of the skull. emDOCs subscribes to the Free Open Access Meducation.
The clinical term burr hole refers to a surgical operation where neurosurgeons produce a small hole in your skull 1. Monday Friday, 7 a.m. 5 p.m. A 53-year-old female with no significant past medical history presents to the Emergency Department (ED) with headache after syncope while on a treadmill. The clot of an epidural hematoma will be obvious as it separates the inner table of the skull from the dura. There should be a reminder to use the software features to measure the thickness of the skull, and not try direct comparison, as shown in the image. Incise the dura with a fine Mayo scissors or a #11 scalpel blade (Figure 116-9B). Burr holes can be lifesaving on rare occasions when the patient is worsening neurologically or has blown a pupil and CT scan is unavailable. The perforator bits have a sharp point. When burr holes were positive, the first burr hole was on the correct side 86% of the time when placed as suggested above. Shave the scalp at least 5 cm in all directions from the proposed skin incision. The average time from presentation to trephination at the local emergency department was 55 minutes and to trephination at transfer hospital was 207 minutes. If a subdural hematoma was noted on CT scan, use a sharp hook (not pictured) to elevate the dura, and use scissors to make a small incision. Her pupil on the right is 8 mm and unreactive and prior to CT was 3 mm and reactive. At times, this can be produced by a post-traumatic aneurysm or arteriovenous fistula. I think the caliber of the EZ IO would be too small to allow removal of the clot, no? Surgeons will use this hole to drain blood or other fluid causing pressure on the brain. Contact us at [emailprotected]. B. CT scan of an epidural hematoma.
A large area of the temporal region is shaved and prepared in a sterile manner with betadine/chlorhexidine and a local anesthetic injected subcutaneously using a 25G needle. C. A hole has been made with the perforator bit. Furthermore, the prognosis of patients with traumatic herniation is poor. Print them out and be ready to go over it with your learners! B. Traction is placed on a suture that has been placed through the center of the exposed dura. We placed a sterile dressing on the wound, and the helicopter team transported the patient to the pediatric trauma center. Copyright 2020 Fort Worth Brain and Spine Institute |, To drain blood after a traumatic injury from the, To place any object or medical devices, such as a shunt or chemotherapy wafers. The guard should be set at the appropriate depth. Provides access to middle fossa (the most common site of epidural hematoma) and usually allows access to most convexity subdural hematomas, as well as proximity to middle meningeal artery in region of pterion, 2.if no epidural hematoma, the dura is opened if it has bluish discoloration (suggests subdural hematoma(SDH)) or if there is a strong suspicion of a mass lesion on that side, 3. if completely negative, usually perform temporal burr hole on contralateral side, 4. if negative, further burr holes should be undertaken if a CT cannot now be done, 5. proceed to ipsilateral frontal burr hole. Insert a nasogastric tube to decompress the stomach. Use suction to remove the bone fragments and the irrigation fluid. Please review before submitting. A regular course of antibiotics will prevent any post-surgical infections in the surgical site. For this reason, most brain surgery requires to place a hole in the skull to treat the injury or illness. Emergency burr holes: How to do it. 1) We find it easier, when encountered a clot that wont extrude, to irrigate gently with sterile saline. In order to access the brain tissue, surgeons will open the skull to get access to the brain. Sure, if we stop and think about it, we all know that the CT images on our screen are not life-size, but I worry that, in the midst of a very stressful scenario, first thing someone will recall about this article is that image.
Place the patient supine with a folded blanket or towel under the ipsilateral shoulder. 5) Cleanse the skin first using 70% alcohol followed by povidone iodine or chlorhexidine solution. The Burr Hole surgery requires a well-trained neurosurgeon, a neurologist, an anesthesiologist, and a nursing assistant to perform successfully. Accessibility A. No Neurosurgeon available in a reasonable time frame, The decision to drill through someones skull should not be made lightly, and so the indications for such an event must be clear. Emergency department skull trephinations should only be performed in the temporal region to avoid venous sinus injury and complications of air embolism or hemorrhage. Once the bone fragment is removed, the clot may not immediately extrude. Neurosurgeons may do a burr hole procedure to relieve pressure around the brain because of: Bleeding in the area around the spinal cord (epidural hematoma), Buildup of cerebrospinal fluid (CSF) around the brain (hydrocephalus), Certain kinds of bleeds from the brain itself (rare). Wilson, M.H., Wise, D., Davies, G. et al. The two nonautomated choices for trephine are the Integra hand crank model with stopper (see Figure 1) and the Galt trephine (see Figure 2). Start with a temporal burr hole on the side: 1. ipsilateral to a blown pupil.This will be on the correct side in> 85% of epidurals Shave the hair with clippers; sterile prep and drape. Prepare the patient. Make a nick in the dural with an 18 gauge needle or a #11 scalpel blade. Todays Unlocking Common ED Procedures post looks at an uncommon but emergent procedure: the burr hole for cranial decompression. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683§ionid=45343759. Salama, H. Outcome of single burr hole under local anesthesia in the management of chronic subdural hematoma. Perform a ventriculostomy using an appropriate ventricular catheter. These risks may vary according to the patients age, overall health condition, and the reason for this procedure. Recipients may need to check their spam filters or confirm that the address is safe. Apply the trephine with gentle, steady pressure until the skull is penetrated. This includes pupillary dilation with a decreased or absent light reflex, progressive deterioration in the patient's level of consciousness, and/or hemiparesis including posturing (decerebrate/decorticate) or flaccidity.
Control bleeding from the bone with bone wax and from the epidural space with Gelfoam. 1981; 8:551554, McKissock W, Taylor JC, Bloom WH, et al. Once the bone fragment is removed, the clot may extrude spontaneously or require gentle suction with a catheter. The bits come in a variety of shapes and sizes (Figure 116-5). The dura is usually not closed. The assessment should include hemodynamic parameters, Glasgow Coma Score, and frequent neurological examinations. Secondary injuries can evolve, even after adequate hematoma evacuation. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683§ionid=45343759. Suspect a space-occupying lesion when there is clinical evidence of tentorial herniation or upper brain stem dysfunction. Grasp the rotating handle with the dominant hand. 2) When you break the inner table of the skull with the Galt trephine, it is subtle.