LRH · EMERGENCY DEPARTMENT
Emergency Burr Hole
INDICATIONCT-proven extradural / subdural hematoma with GCS <8 + pupil asymmetry, and definitive neurosurgery >2 h away — only after a neurosurgical phone consult, with the transfer already rolling.
EQUIPMENT
TRAUMA CART · BURR HOLE shelf
(scalpel also in SCALPEL drawer)
- Drill: Codman disposable perforator (site-stocked, clutched/self-stopping); Hudson brace backup
- Non-clutched set: penetrator bit + blunt burr bit for the inner table
- IO (EZ-IO-type) drill — improvised alternative
- Scalpel + self-retaining retractor
- Suction + sterile saline — assistant irrigates while drilling
- Sharp dural hook / fine artery forceps
- Bone nibbler — enlarge the hole if needed
PREP + DRUGS
- Clippers/razor · chlorhexidine
- Lidocaine 1% with epinephrine ~10 mL
- Cefazolin 2 g IV before drilling
FIG 1 · THREE SITES + SKULL LANDMARKS (ALFRED STAR, LATERAL)
STEPS
- Phone neurosurgery FIRST. Drill only when definitive care is not reachable within ~2 h; with CT, drill where the clot is thickest.
- Intubated, sedated ± paralyzed, head up 30°; shave widely, prep, infiltrate lidocaine + epinephrine.
- Site — temporal first: 2 finger-breadths anterior + superior to the ear, above the zygomatic arch — the side of the blown pupil / CT lesion (~75% of extradurals).
- Incise 4 cm down to bone; retract; scrape off periosteum. Expect superficial temporal artery bleeding — control it.
- Drill perpendicular to the skull, firm steady pressure, saline irrigation. Clutched bit stops itself at loss of resistance; non-clutched — penetrate the outer table, then switch to the blunt burr for the inner table.
- Let extradural clot extrude on its own — gentle irrigation / gentle suction only. Never suction on brain.
- Dura intact + subdural on CT: lift the dura with the sharp hook, nick carefully with the scalpel to release.
- No clot → repeat at frontal (10 cm above the eye, mid-pupillary line) → parietal, same side.
- Neuroprotection for transfer: head up 30°, no neck ties, PaCO₂ 35–40 mmHg, MAP >90, deep sedation/paralysis → urgent transfer for definitive craniotomy.
This buys transport time, not definitive care. Plunging through the inner table is the disaster — use the clutched bit, or two stages with the blunt burr.