EMERGENCY DEPARTMENT · WALL POSTER

Emergency Burr Hole (Craniotomy)

DECIDECandidate: CT clot + herniating despite max therapy, neurosurgery >2 h away. Consult neurosurgery for decompression planning. · Temporal: 2 finger-breadths forward and 2 up from the ear canal, above the zygoma. Use the side of the CT lesion; with CT, drill where the clot is thickest. · Frontal: ~10 cm above the orbital rim, mid-pupillary line. Stay off the midline. · This gains time for transport; it is not definitive care.

STEPS · ◆ KEY STEP — LOGGED WITH ITS TIME

DRILL — STEP BY STEP

Prepare: intubated and sedated, head up 30°, shave and prep wide, cefazolin 2 g IV.
Incise 4 cm down to bone; insert the self-retaining retractor; scrape the periosteum off.
Drill perpendicular, firm steady pressure, assistant irrigating with saline. ◆ BURR HOLE OPENED
Codman: select the 3/8 inch bit.
Drill three holes in a triangle, about 2 cm on a side.
Rongeur or nippers: nip away the bridges, connecting the three holes into one triangular opening — an adequate drainage area.
Let extradural clot extrude on its own — gentle irrigation and suction only; never suction on brain.
Subdural on CT with dura intact: lift the dura on the hook and nick it.
Transfer: head up 30°, no neck ties, PaCO₂ 35–40, MAP >90, deeply sedated. Re-deteriorates en route → PaCO₂ briefly to ~30, mannitol 0.5–1 g/kg or hypertonic saline.

EQUIPMENT

Drill: Codman disposable perforator, clutched and self-stopping.
Bit: clutched perforator. Otherwise non-clutched for the outer table, blunt burr for the inner.
Scalpel (4 cm incision), self-retaining retractor, suction, sterile saline for irrigation.
Lidocaine 1% with epinephrine (~10 mL); razor or clippers to shave widely.
Sharp dural hook or fine artery forceps; bone nibbler in case the hole must be enlarged.
Cefazolin 2 g IV before drilling.

IN THE KIT — 9 ITEMS · TRAUMA CART · SHELF A

Codman disposable perforator — clutched / self-stopping ×1
Hudson brace or driver — whichever your perforator fits ×1
Scalpel No. 10 blade — 4 cm incision ×1
Self-retaining retractor ×1
Sharp dural hook ×1
Bone nibbler — in case the hole must be enlarged ×1
Lidocaine 1% with epinephrine 10 mL + syringe ×1
Clippers — shave widely ×1
Sterile saline 500 mL for irrigation ×1

ALSO NEEDED — NOT IN THE KIT

Cefazolin 2 g IV comes from the Omnicell, not the tray. Suction is set up separately.
DRAFT — not yet assembled or signed off. Confirm the perforator is the clutched, self-stopping type before it is stocked.

FIGURE

Alfred STAR landmark set: temporal hole two finger-breadths anterior and two superior to the ear (external auditory meatus), above the zygomatic arch — directly over the middle meningeal artery. Frontal hole ~10 cm above the eye in the mid-pupillary line; parietal hole posterosuperior to the ear.

TEMPORAL: 2 FB ANTERIOR + 2 FB SUPERIOR TO THE EAR

FRONTAL: 3 CM OFF MIDLINE · CORONAL SUTURE · MID-PUPIL

INCISION 4 CM · LIDO+ADR ~10 ML · CEFAZOLIN 2 G IV

GATE: GCS <8 + PUPIL ASYMMETRY + >2 H TO NEUROSURGERY

TRANSFER: HEAD UP 30° · PACO₂ 35–40 · MAP >90

PITFALLS & PEARLS

Plunging through the inner table into brain.

Superficial temporal artery bleeding from the scalp incision obscuring the field — control it before drilling.

Hole too small to pass solid clot or see the middle meningeal bleeder — enlarge with the nibbler.

Doing it at all without a neurosurgical discussion or CT localization.