II. Indications
- Acute Subdural Hematoma or Epidural Hematoma with rapid deterioration and signs of acute Herniation
- Significant delay until definitive management by neurosurgery
III. Technique
- Define site of Hematoma on CT Head
- If Hematoma site is not accessible via standard landmarks, discuss alternative sites with neurosurgery
- Landmarks (standard, safest location without venous sinuses)
- Two finger breadths anterior to auditory canal
- Two finger breadths above zygoma (level of zygomatic arch)
- Procedure
- Assistant stabilizes the head position
- Mark, prep and anesthetize scalp region
- Make a vertical incision (3-5 cm long) down to bone
- Incision large enough to expose skull for burr tool application
- Self-retaining scalp retractor to expose periosteum
- Use periosteal elevator to elevate periosteum from skull
- Apply and use Burr tool with care to avoid plunging
- Transition from outer to inner skull table will feel like moving from smooth to rough
- Epidural Hematoma will drain spontaneously after passing through inner skull table
- Additional 3-sided incision flap through dura will be needed in cases of Subdural Hematoma
- Apply sterile dressing
- Alternative (Experimental, case reports only from low resource centers)
- Case report of successful trephination with EZ-IO (Intraosseous Cathether Placement)
- Case report used the same landmarks as Burr Tool (see above)
- Use standard adult EZ-IO (25 mm, blue intraosseous needle) and hubbed the catheter
- No cut-down to skull was performed (EZ-IO inserted directly through skin, as done with standard IO)
- References
IV. Efficacy
- Non-neurosurgeon performed emergency trephination is associated with improved outcomes (when neurosurgery not available)
V. References
- (2021) EM:Rap 21(1): 2-3