- Indications for rural neurosurgical intervention
- Neurologically deteriorating pt and can’t do CT head
- T/F to nearest N/S unit is > 2 hours away
- Sizable intracranial haematoma
- Indications for Burr hole
- GCS 8 or less with imaging showing epidural haematoma causing midline shift and unequal pupils
- High clinical suspicion with palpable #, ipsilateral fixed dilated pupil and deteriorating neurology without imaging
- Burr Hole technique
- Confirm side and position → Shave and prep
- LA and 3cm incision to bone
- Periosteal elevation and self-retainer
- Hudson brace manual burr used perpendicular to skull with saline being applied for bone dust
- Stop when resistance gives
- Perforator for conical opening widened by cylinder burr
- Epidural clot should evacuate now
- If it doesn’t = Subdural → Open dura with knife
- If no blood - confirm side/scan and if bleeding on-going DO NOT TAMPONADE
- Transfer patient
- Locations:
- Temporal - 1cm above Posterior Zygomatic Arch
- Frontal - 10cm above pupil - over the Coronal Suture approx 10cm cephalad and in line with the Mid-Pupillary line
- Parietal - 5cm above ear - over the Parietal Eminence
- Emergency Frontotemporal Craniectomy
- Scalp incision from ant to ear curving up and anteriorly to follow temporal plane
- Raise flap
- Serial burr holes include edge of # and combine with Gigli saw
- Elevate bone flap
- Don’t dig out bone fragments from bone parenchyma - causes more injury
- Death occurs due to on-going bleeding → High ICP → Brain shift and herniation causing brain stem damage
