Burr holes

[Veneficus]

This topic came up in a recent discussion with FLdoc.

As part of that discussion, I solicited an informal poll on my FB page about whether or not emergency physicians in community hospitals. (to mean where neurosurg is not on staff,) if they would be willing to drill a burr hole for relief of a possible herniation.

At least one of the responding attending EMs reposted it on his page(with responses from 6 attending EMs and 1 senior EM resident in the US), I recieved 2 private messages regarding the issue from an anesthesiologist who is the head of a large ED at an academic facility and trauma center on this continent, and an orthopod who works with the local EMS. I also solicited the verbal opinion of a neurosurgeon.

I was surprised at the results. (I figured for sure most would not)

It was reported by all respondants that they would in fact resort to attempting to drill a burr hole for relief of ICP.

All except the neurosurgeon added with various degrees of reservation.

Neuro said relief of ICP is considered the lowest level of neurosurg training often relegated to 1st year residents.

He also mentioned that burr holes would likely not be enough and that a cranial flap be removed.

So I felt I should refer to a published text for an opinion.

Having a copy of Fischer's Master of surgery handy, I looked there.

Just as the neuro guy mentioned, it suggests a "hemicraniotomy" (aka trauma flap). It of course goes on to detail how to perform the procedure because that is the purpose of the text.

It was interesting to note the procedure dictates drilling several burr holes as part of the initial procedure, before basically "connecting the dots" to form the flap.

In a quick medscape search, the only results that returned with the effectiveness of burr holes in reducing ICP was related to lateral ventricular tumors.

The results for TBI all listed the effectiveness of hemicraniotomy. With at least one suggesting it be done bilaterally for greatest effect.

Based on this, I adopt the mindset that burr holes are just not going to work to significantly relieve herniation. (all information here was passed on to those who were gracious enough to respond)

I am waiting to hear back on whether or not those same respondants are willing to "go large or go home" and perform an emergent hemicraniotomy.

Just thought everyone would like to know the results.

 

[jjesusfreak01]

Super interesting question. While I haven't even started medical school yet, I do aspire to be an emergency physician, so i'll chime in.

I for one would be hesistant to try a burr hole unless,
1. I thought the patient's death was imminent without the procedure.
2. There wasn't a more qualified doc who could be at the hospital within a reasonable amount of time.

I currently live near a number of level 1 trauma centers with neurosurgery residents on call anytime, so we would need to be in a fairly remote area, say at least 2 hours from a more capable facility.

If the patient could not be stabilized for transport or a surgeon couldn't make it to my hospital, then sure, why not? The only real problem here comes with liability if and when the patient dies (and they are probably going to die if you're doing a craniotomy, since they've already sustained some high level of damage to the brain). My (theoretical) hospital would probably frown on me doing the procedure, as would my liability insurance.

 

[FLdoc2011]

Good poll and interesting results.

From what I've heard/seen burr holes is a skill/procedure that's certainly within most ED trained docs ability, especially if they're ER residency trained at a trauma center. Certainly a skill that's not used often thankfully but there if needed. I'm not sure about crani's though.... I'd imagine that's the point they'd call it a day or something. As part of training they usually do a few months of trauma surg so I'm sure they're exposed to it.

 

[Aprz]

So is a hemicraniotomy just a larger hole (multiple Burr holes connected) vs. Burr hole is probably small?

 

[NYMedic828]

So is a hemicraniotomy just a larger hole (multiple Burr holes connected) vs. Burr hole is probably small?

From how veneficus described it, it sounds like it is actually a flap almost like a trap door made into the cranium.

They use the drill to make a bunch of burr holes in a line, essentially using it to cut lines of dots that can be removed to truly relieve pressure in the cranium.

What I believe he was getting at by the end of his post, is that a tiny burr hole is simply not enough to relieve truly rising ICP in any efficient manor.

Once all is said and done I imagine some measures such as plates and screws would be used to re-install the piece of the cranium.

 

[Aprz]

Then are Burr holes just a step in hemicraniotomy and considered an outdated procedure for treating increasing intracranial pressure, or do they serve some other purpose? Maybe prophylactic/preemptive?

 

[jwk]

From how veneficus described it, it sounds like it is actually a flap almost like a trap door made into the cranium.

They use the drill to make a bunch of burr holes in a line, essentially using it to cut lines of dots that can be removed to truly relieve pressure in the cranium.

What I believe he was getting at by the end of his post, is that a tiny burr hole is simply not enough to relieve truly rising ICP in any efficient manor.

Once all is said and done I imagine some measures such as plates and screws would be used to re-install the piece of the cranium.

Actually, they would usually make about 4 burr holes in a square or rectangular shape, then make curving cuts with a little saw and connect the dots. I've never seen this done in an ED - but I've never worked at a hospital without pretty quick neurosurgery coverage either.

 

[Veneficus]

"My Roberts & Hedges procedural text doesn't have burr hole technique listed."

Was one of the replies.

No idea who Roberts & Hedges is, but I am guessing it is basically a procedure manual for EM based on the amazon description.

http://www.amazon.com/Clinical-Proc...6237/ref=sr_1_1?ie=UTF8&qid=1333021049&sr=8-1

One of the doctors suggested using an EZ-IO if it came to desperation. We unanimously agreed to write up and name the procedure after him if it worked.
(Please don't call medical control and ask to do that on your next TBI)

I am sure there is a picture of the procedure on google or youtube somewhere.

I really appreciated the response:

"I would call neurosurg and ask them to walk me through it."

I can't decide if that was phoning a friend or asking an expert. Better than asking the audiance I guess...

All of the respondants work in major academic centers though. So it was rather hypothetical for them. (and I suspect they are a bit more aggresive in care for it, but I also thought most would be reluctant to even try though, so take it for what it's worth)

As with any surgical procedure, it probably isn't going to go perfectly when the conversation starts with:

"How long has it been since you've seen or done this?"

 

[Akulahawk]

Given that a burr hole is just a small hole in the skull... and there's a larger hole still available for the brain to squeeze itself through, I think the role of a stand-alone burr hole is to attempt to evacuate any additional fluid around the brain (such as hematomas and the like) to buy some time to get the patient and surgeon together so that a more definitive therapy can be implemented. I figure that creating a large flap would allow the brain to swell out that direction instead of through the Foramen magnum... and a burr hole would just allow some brain to push it's way through that as well as the Foramen magnum, if it's going to be swelling that much.

But what do I know, I'm just a Paramedic, right?

 

[Veneficus]

Given that a burr hole is just a small hole in the skull... and there's a larger hole still available for the brain to squeeze itself through, I think the role of a stand-alone burr hole is to attempt to evacuate any additional fluid around the brain (such as hematomas and the like) to buy some time to get the patient and surgeon together so that a more definitive therapy can be implemented. I figure that creating a large flap would allow the brain to swell out that direction instead of through the Foramen magnum... and a burr hole would just allow some brain to push it's way through that as well as the Foramen magnum, if it's going to be swelling that much.

But what do I know, I'm just a Paramedic, right?

I don't think a partially clotted and expanding hematoma is going to evacuate through a little hole anywhere in the body.

There must be a reason it is not described in procedural manuals in both EM and surgery.

 

[Christopher]

Interesting you bring this up, I was just reading a paper by Dr. Stephen Smith (of Hennepin County) on skull trephination for ED docs and an accompanying blog post by Dr. Cliff Reid (of the Greater Sydney Area Helicopter EMS) on the subject.

Apparently Hennepin County Medical Center runs a Comprehensive Advanced Life Support class for rural emergency medicine physicians which covers how and when to use burr holes:

Conclusion: In T&D patients with CT-proven EDH and anisocoria, ED skull trephination before transfer resulted in uniformly good outcomes without complications. Time to relief of intracranial pressure was significantly shorter with trephination. Neurologic outcomes were not different.

As for getting the clots out, apparently they use suction or hemostats to pull any out which clog the hole.

Literature seems to support ED docs doing it, if they have the training and the patient will have to wait a while for neuro intervention.

 

[Veneficus]

Interesting you bring this up, I was just reading a paper by Dr. Stephen Smith (of Hennepin County) on skull trephination for ED docs and an accompanying blog post by Dr. Cliff Reid (of the Greater Sydney Area Helicopter EMS) on the subject.

Apparently Hennepin County Medical Center runs a Comprehensive Advanced Life Support class for rural emergency medicine physicians which covers how and when to use burr holes:


As for getting the clots out, apparently they use suction or hemostats to pull any out which clog the hole.

Literature seems to support ED docs doing it, if they have the training and the patient will have to wait a while for neuro intervention.

A good set of reading, but both dealing with epidural hematoma specifically and patients who present in a specific manner.

I don't see why a rural EM or any other provider couldn't be taught the physicasl skill how to do skull flaps.

Equipment and desire would be another matter.

 

[Christopher]

I don't see why a rural EM or any other provider couldn't be taught the physicasl skill how to do skull flaps.

Equipment and desire would be another matter.

Agreed. It would be a low frequency, high skill operation as I imagine it not to be without potential major problems. If you're far enough out into the boonies, the risk-benefit for your patient is probably worth it!

 

[mycrofft]

Maybe best in case of epidural issues, manipulating an accidentally mobilized section of skull, or to let out evil spirits.

Read the posts elsewhere and tell me you would want even a sizable minority of these kids working on your loved one like that?

 

[Veneficus]

Maybe best in case of epidural issues, manipulating an accidentally mobilized section of skull, or to let out evil spirits.

Read the posts elsewhere and tell me you would want even a sizable minority of these kids working on your loved one like that?

I was thinking of physicians when I wrote that.

I know that some rural EDs still use whoever will work, they are not confined to EMs.

 

[mycrofft]

Ah, a voice of reason!

 

[TatuICU]

Would be pretty ballsy for a family practice resident moonlighting in a rural ER (as a lot of them are). I think a lot of them are comfortable with idea of burr holes to the point of perhaps answering poll questions via the internet, but when the rubber hit the road and the patient presents with signs of herniation, they'd probably be more concerned with getting their transfer paperwork in order and getting them the hell out of there. Seen 1 doc do it in a rural ER in 10 years. Just my experience.

 

[Veneficus]

Would be pretty ballsy for a family practice resident moonlighting in a rural ER (as a lot of them are). I think a lot of them are comfortable with idea of burr holes to the point of perhaps answering poll questions via the internet, but when the rubber hit the road and the patient presents with signs of herniation, they'd probably be more concerned with getting their transfer paperwork in order and getting them the hell out of there. Seen 1 doc do it in a rural ER in 10 years. Just my experience.

Many of the people I associate with are "work hard, play hard" types.

"Average" is not a word I would use to describe them. (Most are EM trained attendings for some strange reason too)

If they say they would do it, I believe them.

But it is sort of like adding a 250 saline bag to a hemorrhaging patient, go large or go home, conservative treatment will not due.

 

[Merck]

I'm thinking that the idea of a rural doc deciding to drill a hole into a patient's head is probably a bad idea. As was eluded to earlier, a small burr hole will likely do nothing to relieve ICP as there are other places for brain matter to go (i.e. foramen).

Also, a burr hole will likely only be useful for an epidural or SDH, not an intracerebral bleed or SAH. Many more rural places I visit don't even have access to CT so the chances of a burr hole being attempted are minimal.

To be honest, I think there would be more to be gained from common guidelines that are actually implemented well rather than muddying the waters with Doogie Howser stuff. Focus on low normal PCO2, neuroprotective intrubations, elevated HoB to promote venous drainage and lower PEEP settings with prompt evacuation to a neuro guy.

As an aside, can't say I'd agree with the go large or go home philosophy either, especially with fluid in trauma.....

 

[Doczilla]

If the burr holes are placed properly, you won't herniate into the foramen magnum. that's the whole point of choosing the site.

MRI can substitute a CT if nothing else. Then there's angiography. The lesser bleeds can certianly be flown out to a level 1 or 2, being that they are not ARTERIAL bleeds being pumped into a skull.