- Scraping bone (see Figure 3)
- Drilling a series of small holes and connecting them
- Making crosshatch cuts in the bone and connecting them to remove a rectangular piece of bone1
Discussion
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ACEP Now: Vol 36 – No 12 – December 2017Figure 3. Bronze Age skull from Jericho, Palestine, 2200–2000 BC. The skull shows four separate holes made by trephination that had begun to heal, indicating that the patient survived the procedure.
Wellcome Images/Science Source
The medical literature supports skull trephination by emergency physicians in emergency departments without immediate neurosurgery capability for the talk-and-deteriorate patient with anisocoria, Glasgow Coma Scale (GCS) score <9, and CT-proven epidural hematoma (EDH). The available studies are retrospective and small.1,3,4 A small (n=5) retrospective chart review by Smith et al examined all known cases of skull trephination done by emergency physicians at non-neurosurgical institutions before transfer to a neurosurgical institution.1 The mean time saved to decompression by emergency department intervention was two hours without complications. The Galt trephinator was used. This small study of talk-and-deteriorate EDH patients resulted in uniformly good outcomes without complications.
A second study by Poon et al reported rapidly deteriorating patients with EDH who presented to a neurosurgical institution had a mean time to EDH evacuation of 0.7 ± 1.0 hours, with nine of 11 patients having good outcomes. For 12 patients with EDH presenting to hospitals without neurosurgery and no ED trephination, the time to evacuation, once transferred to a neurosurgical institution was 3.2 ± 0.5 hours, with mortality of 67 percent (eight of 12 patients).3
Cohen et al found that EDHs not drained within 70 minutes of onset of anisocoria are associated with poor outcome.5 Taking these critical time windows into account, it makes sense that talk-and-deteriorate patients have the potential to greatly benefit from emergency department skull trephination in institutions without neurosurgical capabilities. Nelson studied 11 patients with local non-neurosurgeon drainage of epidural hematoma prior to transfer to neurosurgical centers, and the data showed consistently favorable outcomes.4
In 2016, the Brain Trauma Foundation and the Congress of Neurological Surgeons stated, “It is strongly recommended that patients with an acute EDH in coma (GCS<9) with anisocoria undergo surgical evacuation as soon as possible.”6 Additionally, the Brain Trauma Foundation states, “There are insufficient data to support one surgical treatment method. However, craniotomy provides a more complete evacuation of the hematoma.”6
As emergency physicians, it is our duty to rule out the life threats and be prepared to reverse life-threatening conditions with heroic procedures we often have never performed. If you practice at a hospital without neurosurgery, skull trephination is a tool you can use to save a life one day.
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9 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!
December 9, 2020
PradeepWow! It’s sounds just like one of those scenes from those medical dramas. I always wanna test my skills under pressure but at the same time i hope those situations doesn’t occurs to me. Kudos to you sir for keeping your cool and thanks for sharing your experiences
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?
September 6, 2019
Con DavUsing an IO device to make a circle of small holes and connect them has been described.
February 12, 2024
Charles Monday, Jr., M D FACS, retiredGS practice, rural, 70 mi N of Houston, Tx. Advised by lecturing neurosurgeon to NOT do burr hole for fear of lawsuit with this condition(having less than 10% chance of survival) based on pupil, etc. before we had C T Scanner.) Now we do, of course. However now, with handy helicopter service, the patient might reasonably burr holed by neurosurgeon within 90 minutes.
What to do?