Surgical - Craniotomy

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This procedure is rarely performed by emergency physicians.

Every effort should be made to discuss case and procedure with a neurosurgeon prior to intervention.

Indications

Extradural or subdural haematoma with midline shift on CT, or

High clinical suspicion if CT unavailable (head trauma, rapidly deteriorating course)

and

GCS <8 with unequal pupils on examination

and

Inability to access neurosurgical assistance within two hours

Contraindications (absolute in bold)

Lack of imaging-confirmed epidural or subdural haematoma

Alternatives

Rapid transport to a neurosurgical centre with neuroprotective measures

Bringing a neurosurgeon to the patient

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

Potential complications

Failure (clotted blood, absence of blood at site)

Bleeding (scalp and superficial temporal artery)

Damage to brain parenchyma

Infection

Procedural hygiene

Standard precautions

Aseptic non-touch technique

PPE: sterile gloves and gown, surgical mask, eye protection

Area

Resuscitation bay

Staff

Procedural clinician and two assistants

Equipment

Razor

Scalpel

Retractor

Manual (Hudson brace) drill or powered neurosurgical drill

Clutched penetrator drill bit (preferred) or

Non-clutch penetrator (sharp) and burr (blunt) drill bits

Suction and saline

Sharp hook or artery forceps (to grasp dura)

Additional artery forceps (to control potential superficial temporal artery bleeding)

A clutched penetrator drill bit can be used to drill through the skull in one motion. It is designed to disengage on penetrating the inner table of the skull (reducing ‘plunging’ and brain injury). Without a clutch, a penetrator bit must be changed to a blunt burr drill bit after initiating the craniotomy to reduce the chance of plunging into brain tissue.

Positioning

Intubated, anaesthetised, paralysed with C-spine immobilisation

Supine with head supported by assistant, injured side tilted up if possible

Three sites are available for craniotomy:

Temporal - two finger-widths anterior and superior to the auditory canal (avoiding temporal artery)

Frontal - 10cm above the eye in the midpupillary line

Parietal - four finger-widths posterior and superior to external auditory canal

With CT scan: perform at site with greatest depth of haematoma

Without CT scan: perform temporal craniotomy on side with pupillary dilation

Medication

10ml lignocaine 1% with adrenaline (1:100,000)

2g cephazolin IV

Sequence

Shave scalp widely over selected site

Infiltrate local anaesthetic with adrenaline at chosen site

Use scalpel to make a 4cm incision down to bone

Apply retractor to expose skull

Scrape periosteum with scalpel (improves contact drill bit)

Use the drill and clutched penetrator drill bit to penetrate through entire skull (if available), or

Use the drill and non-clutched penetrator drill bit to penetrate through outer table of skull, then

Use the drill and burr drill bit to cautiously penetrate through inner table

Apply drill perpendicular to skull and begin drilling while applying firm pressure

Have assistant apply gentle saline wash to drilling site

With a clutched drill bit continue drilling until loss of resistance felt or drill bit stops spinning

With a burr drill bit regularly assess progress and cease drilling when the inner skull has been penetrated

Blood and clot can now escape from extradural space through opening

Allow blood to drain freely (gentle suction may be used, but do not suction brain tissue)

Flush gently with normal saline and suction gently if required

If subdural haematoma suspected, elevate dura with sharp hook and make careful incision with scalpel

If no clot evacuated, proceed with same technique at the frontal and parietal two sites on the affected side

If no clot evacuated from all three burr holes, repeat technique on the other side

Once blood flow slows or stops, apply loose dressing

Post-procedure care

Rapid transport to a neurosurgical centre applying standard neuroprotective measures:

Supine position 30 degrees head up without restricting neck ties

Adequate sedation and antiemetic

Oxygen to maintain saturations

PaCO2 should be maintained at 35-40mmHg

Mean arterial pressure >90mmHg

Isotonic crystalloids to maintain euvolaemia

Apply active neuroprotective measures for pupillary deterioration (asymmetry, dilation or non-reactive):

Hyperventilate to 30mmHg PaCO2 for 5-10 minutes, ceasing if the signs resolve, plus

Intravenous 20% mannitol: 0.5-1gm/kg body weight over 20 minutes, or

Hypertonic saline: 6-8ml/kg of 3% solution, or 4ml/kg of 7.5% solution

Tips

Expanding intracranial haematoma is rapidly fatal and requires early therapeutic intervention

Temporal burr holes are performed first as 75% of extradural haematomas are temporal

The scalp and superficial temporal artery (if incised) will bleed profusely

Clot may be semisolid in extradural haematoma requiring enlargement of craniotomy under neurosurgical advice

Where a CT scan is not accessible, skull X-ray can provide information on skull fractures

Non-neurosurgical drills have been successfully used when no dedicated drill is available

Discussion

Resuscitative craniotomy is rarely performed by emergency physicians. Trauma surgeons and general surgeons practicing in remote locations are often trained in this procedure. Occasionally, emergency physician resuscitative craniotomy may be indicated and life-saving.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Greater Sydney Area Helicopter Emergency Service

CareFlight

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Neurosurgical Society of Australasia. The management of acute neurotrauma in rural and remote locations. 3rd ed. Melbourne: Neurosurgical Society of Australasia; 2009.

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Smith SW, Clark M, Nelson J, Heegaard W, Lufkin KC, Ruiz E. Emergency department skull trephination for epidural hematoma in patients who are awake but deteriorate rapidly. J Emerg Med. 2010;39(3):377-383. doi:10.1016/j.jemermed.2009.04.062

Wilson MH, Wise D, Davies G, Lockey D. Emergency burr holes: "How to do it". Scand J Trauma Resusc Emerg Med. 2012;20:24. Published 2012 Apr 2. doi:10.1186/1757-7241-20-24

Mendelow AD, Karmi MZ, Paul KS, Fuller GA, Gillingham FJ. Extradural haematoma: effect of delayed treatment. Br Med J. 1979;1(6173):1240-1242. doi:10.1136/bmj.1.6173.1240

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