Your patient presents with a large traumatic subdural hematoma with midline shift and clinical evidence of herniation.  Your nearest neurosurgeon is several hours away, what do you do?

Initial resuscitation should follow ATLS.  Treatment of intracranial hypertension and herniation includes elevating the head of bed, administering osmotic therapies, optimizing analgesia/sedation, and hyperventilation.  If all measures have been exhausted and there is a delay to definitive neurosurgical intervention, an emergency department burr hole may be considered.

Indications:

• GCS < 8, dilated and nonreactive pupil(s), posturing suggestive of uncal or transtentorial herniation 
• Radiographic evidence of an extra-axial (subdural/epidural) hematoma causing midline shift and brainstem compression
• Lack of timely neurosurgical intervention
• Procedure will not delay transfer to definitive care

Contraindications:

• Neurosurgical intervention available within reasonable time frame
• Skull fracture at site of planned burr hole

Equipment:

• Razor
• Surgical marker
• Sterile prep and drape
• Syringe, needle, lidocaine
• Scalpel, forceps, retractor, sharp hook, scissors
• Hand drill, hex wrench, drill bit with guard
• Sterile saline, gauze, dressing

Transtemporal Approach:

• Measure skull thickness on CT for depth of drill guard.
• Position patient supine and elevate the ipsilateral shoulder with a shoulder roll.  Utilize tape or have assistant hold the head in place. 
• Shave the hair.
• Mark the point 2 cm superior and 2 cm anterior to the tragus.
• Sterile prep and drape.
• Inject local anesthetic and then make a 3 cm vertical skin incision down to the periosteum.  Dissect and use a retractor to expose the skull.
• Drill with steady pressure perpendicular to the skull.  Irrigate with sterile saline to remove bone fragments.
• Once the skull is penetrated:
  • If an epidural hematoma, blood should be released.  Can use sterile saline to facilitate drainage of clotted blood.
  • If a subdural hematoma, use a sharp hook to tent the dura and make a small cruciate incision.
• Place loose sterile dressing.
• Transfer to definitive care.

Additional Points:

• Neurosurgery consultation before performing this procedure is recommended. 
• Antibiotic prophylaxis with gram-positive coverage is recommended.
• In extenuating circumstances, this may be considered without CT confirmation of the location of the extra-axial hematoma.  However, there is risk of a negative exploratory burr hole due to a hematoma not in the temporal location or due to a false localizing sign.

References

• Wilson MH, Wise D, Davies G, Lockey D. Emergency burr holes: “How to do it.” Scand J Trauma Resusc Emerg Med. 2012 Apr 2;20:24.
• Donovan DJ, Moquin RR, Ecklund JM. Cranial burr holes and emergency craniotomy: review of indications and technique. Mil Med. 2006;171(1):12-9.
• Hsu E, Buffin N. Unlocking Common ED Procedures – Crackin’ the Cranium: A Review of Cranial Burr Hole Decompression. emDOCs.net  http://www.emdocs.net/unlocking-common-ed-procedures-crackin-the-cranium-a-review-of-cranial-burr-hole-decompression/ Published April 9, 2020. Accessed October 13, 2021.

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