Rural Medicine: Cranial Burr Holes
Jess Mason, MD and David Beffa, MD
- Case: A young child presents with a head injury after a fall from 3-4 foot height onto a hard surface about 45 minutes prior to arrival. The child initially looks fine and the exam is normal except for a right-sided hematoma and hemotympanum. Over the next 15-20 minutes, the child rapidly deteriorated with declining mental status and unequal pupils. CT revealed an epidural hematoma with midline shift.
- Time to neurosurgical decompression is key. In settings where there will be delay to decompression, a cranial burr hole may be indicated.
- Indications for an emergency burr hole may include rapid clinical deterioration (eg,declining GCS, unequal pupils), an expanding hematoma (epidural or subdural), and prolonged time to neurosurgical decompression.
- Don’t forget the basic management of elevated intracranial pressure:
- Elevate the head of the bed.
- Ensure adequate sedation.
- Maintain normoxia and normocapnia
- Give mannitol or hypertonic saline.
- Avoid hypotension.
- EMRAP:HD video on cranial burr hole: https://www.emrap.org/episode/cranialburrhole/cranialburrhole
- Steps of procedure (to be done on the side of the blown pupil)
- Knowing the anatomy from the CT head will be helpful. You can measure the thickness of the skull table so you know approximately how deep you need to go.
- Prepare the site using sterile technique.
- If no CT is available and the procedure is done blind, the entry site is 2 cm superior and 2 cm anterior to the tragus on the ipsilateral side of the blown pupil
- Have an assistant hold the patient’s head hard and steady during the procedure.
- Make a 3-5 cm vertical skin incision down to bone.
- Insert self-retaining scalp retractor to expose periosteum.
- Expose the skull and elevate the periosteum using the periosteal elevator.
- Trephination technique varies by device. You may feel a change from smooth to rough as you move from outer to inner skull table.
- An epidural hematoma will start to drain when you get through the inner table. If a subdural hematoma is present, an additional step is needed which involves a 3-sided incision to form a flap in the dura mater.
- Place a sterile dressing.
Adam D. - January 13, 2021 4:30 PM
Does anyone have any references to this being a suggested or required procedure for Emergency medicine?
Jess Mason - January 14, 2021 9:18 AM
It's a really rare procedure that only falls into the realm of emergency medicine when a neurosurgeon is not available to perform it in the timeline that is needed. In that very rare event it has classically been taught as an emergency medicine procedure. It is in Clinical Procedures in Emergency Medicine (Roberts and Hedges) and other EM texts.
Marc G. - February 9, 2021 9:15 AM
Thank you for posting this, I was able to do one with great success this weekend and save a life....
Jess Mason - February 10, 2021 11:43 AM
Wow, Marc! Thank you for sharing this. You are brave for taking the step to do the procedure and I feel honored to have walked with you in a small way.