As a new medical director, I thought to myself, “What is the worst that could happen at our rural, 12-bed ED?” The scenarios we all know came to mind: pericardiocentesis, thoracotomy, lateral canthotomy, resuscitative endovascular balloon occlusion of the aorta, and skull trephination (burr hole). At our monthly departmental meetings, we reviewed all of these procedures so we would be ready. I ordered the necessary kits so we would have the tools on-site. Our hospital had never even had a skull trephination kit before. The one I ordered arrived the day before a 2-year-old patient arrived at triage.
The Case
A 2-year-old male was brought to the emergency department by his mother after falling out of a shopping cart seat and striking his head. He initially appeared well and was running around the triage room. After a period of observation, he became increasingly somnolent, and on repeat exam, his pupils were slightly unequal. A head CT revealed a large epidural hematoma with midline shift. His pupils quickly became significantly worse at 6 mm and 2 mm, and he became unresponsive. I intubated him and called the nearest pediatric trauma center (one hour away) to begin arranging for helicopter transport. During the conversation with the trauma surgeon at the major academic center, I told him I was planning on doing an emergent burr hole. He said, “I’ve never done one of those—it’s up to you.”
I had seen one of these in residency and went to the supply room to find the newly arrived burr hole kit, took a deep breath, then started to prepare for the procedure by reviewing the CT.
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6 Responses to “How To Perform an Emergency Burr Hole Procedure”
December 28, 2017
Alexander KheradiWhat brand kit did you order for your department? Great article.
January 3, 2018
James NelsonHi Dr. Beffa,
Thank you for publishing this, as well as citing my review. We have learned a few practical things at our institution that I would like to share:
1) We find it easier, when encountered a clot that wont extrude, to irrigate gently with sterile saline. With patience, the clot will come out.
2) When you break the inner table of the skull with the Galt trephine, it is subtle. Check often for the bone fragment in the instrument.
3) Sometimes the bone fragment has broken free but does not pick up with the instrument. Probe the “disc” of bone and if loose, pick it up with Kelly forceps.
4) Don’t give up on a patient. My partner drilled on an elderly man comatose with herniating SDH. I thought he had no chance of survival, let alone recovery. He walked out of the hospital a month later.
5) Order a second Galt trephine.
Sounds like you are off to a great start as a medical director. That two year old will not be the only person you save thanks to your proactive work!
January 4, 2018
Nilantha LenoraGreat article, thanks for sharing.
If it’s all you have, would an EZ IO substitute for a Galt trephine? Would technique differ in any way?
January 15, 2018
Ira WoodFigure 1 apppeaes to be dangerously misleading. It could easily lead one to think that you set the depth stop on the drill by holding it up the CT image on your computer screen. 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. 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.
I have admit that this image pulled me in to read the article. I saw it and wondered how you were using the image to set the depth.
I realize that this sounds like common sense, but common sense is not as common as we’d like to think!
IW
January 15, 2018
Jeff LeinenGreat artical, great care, great Doctor
Thanks
January 16, 2018
Darrell Looney, MDI think the caliber of the EZ IO would be too small to allow removal of the clot, no?