Emergent craniotomy: should emergency physicians be drilling burr holes?

Takeaway

• Emergency physicians staffing remote locations should be trained and equipped to perform pretransfer cranial burr holes, argue the authors of this case series.

Why this matters

• An expanding extra- or subdural hematoma is “akin to and equally as lethal as a tension pneumothorax,” they say, while a chest tube is “an intervention far more invasive and potentially dangerous than drilling a burr hole.”
• Craniotomy is a “straightforward skillset.”
• Authors work ≥2.5 hours from nearest neurosurgeon.

Key results

• 32-year-old presented after motor vehicle collision (MVC) with extradural hemorrhage and midline shift.
  • Guided by surface landmarks, the emergency physician drilled a burr hole and evacuated the hematoma.
  • Pupils returned to normal.
  • Patient reached neurosurgical expertise 8 hours after the accident and ultimately recovered.
• 31-year-old presenting after MVC had extradural hemorrhage with uncal herniation.
  • He too underwent emergency department (ED) craniotomy.
  • Vital signs immediately normalized.
  • He required “extensive craniectomy” upon arrival at neurosurgery.
  • Patient has an “improving central cord syndrome” and normal cognition.
• Both procedures were done in consultation with a neurosurgeon and radiologist.
• Both patients required repeat hematoma evacuation during transfer.
• Literature review suggests prompt pretransfer decompression is associated with better outcomes.

Study design

• Case series, literature review, and discussion.
• Funding: None.

Limitations

• Available literature is limited.