Morning Report: Burr Hole Craniostomy

Burr Hole Craniostomy

Mark H Wilson, David Wise, Gareth Davies and David Lockey. “Emergency burr holes: “How to do it” “Scand J Trauma Resusc Emerg Med. 2012; 20: 24.

1) Ensure indications are appropriate

2) Ensure patient is supine and physiologically optimised (intubated, ETCO2 4.5kPa, normotensive, c-spine protection, mannitol/hypertonic saline as directed by neurosurgeon).

3) Confirm position of hematoma on CT scan and be able to view images while performing procedure

4) Shave a strip of approximately 5 cm of hair where the burr hole is to be made.

5) Mark a 3 cm line of incision.

6) Clean the area with betadine/chlorhexidine

7) Make an incision straight down to bone. Bleeding (e.g. from the superficial temporal artery) can be controlled with direct pressure while continuing the procedure.

8) Push the periosteum off the bone with knife/swab

9) Insert self-retaining retractor

10) Push down firmly with drill and start drilling keeping drill perpendicular to the skull. Ensure an assistant is holding the head still and ideally apply saline wash as you drill.

11) Keep going – do NOT stop (as this will disengage the clutch mechanism which can be difficult to re-engage manually)

12) Drill until the drill bit stops spinning. Remove drill.

13) Use blunt hook to remove remaining bone fragments.

14) Extradural blood should now escape.

15) If the blood is subdural, very carefully open the dura using a sharp hook to tent the dura up, and a new sharp knife to incise the dura in a cruciate manner. Subdural blood is likely to be more clotted and difficult to extrude than extradural. Manual removal of clot (e.g. with forceps or very careful suction) could be considered, but may damage brain and is unlikely to remove sufficient hematoma. If no blood is found either extra or sub-durally, stop, check side, and check location of hole. DO NOT DELAY TRANSFER.

16) If fresh blood is continuing to ooze from the wound, do NOT try to tamponade. Leaving the self-retainer in place may stop the bleeding.