SMART

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Cranial Burr Hole

Equipment

Hair clippers or razor Skin stapler

Skin disinfectant Drain

Drape Gauze

Scalpel

Self-retaining scalp retractor

Cranial drill (hand drill and Hudson-brace shown)

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Review CT Landmarks Reduce scalp bleeding Use CT to identify the site. Measure the If no CT is available: 2 cm superior, 2 cm Inject lidocaine with epinephrine. skull to determine depth to drill. anterior to tragus, ipsilateral to blown Palpate the superficial temporal artery pupil (temporal site). Shave the hair, (STA) and remain anterior to it. prep and drape. 4 5 6

Skin incision Insert the retractor Trephination Make a 3-5 cm vertical incision down to Insert the self-retaining scalp Technique varies with equipment. bone. Control scalp bleeding; the frontal retractor to expose periosteum. Have an assistant stabilize the branch of the STA is often transected. head.

This is for reference purposes only. Consent to photograph was obtained from the patient or family. EM:RAP and the authors assume no liability for use of the techniques described. Local practice, current guidelines, and clinician experience should determine the exact procedural process in any individual patient. © 2020 EM:RAP Inc. SMART

LINK TO VIDEO

™

Cranial Burr Hole

7 A B

Using a Hudson-Brace Drilling with the perforator bit Drilling with the conical burr Use the perforator bit to drill When the drilling motion becomes through the outer table, felt as a jagged, switch to the conical burr to smooth drilling motion. trephinate the inner table of the skull.

Note: the non-rotating hand should provide counter-torque and resist forward motion of the drill.

8 A B

Using a hand or electric drill Set the Stopper Drill through the skull Set the stopper based on the CT to pre- Drill through the inner table of the vent drilling too deeply (typically 0.5-2 skull. cm). Use the largest drill bit in the kit.

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Epidural hematoma Subdural hemorrhage Skin closure Evacuate epidural blood with irriga- For a subdural bleed, make a three- Leave a drain in place as blood will tion and gentle suction. sided (or “X”) incision in the dura. reaccumulate. Close the skin for Use irrigation but do NOT suction. hemostasis.

Note: Burr holes without CT guidance can be done in the following sequence: ipsilateral temporal, contralateral temporal, ipsilateral frontal, ipsilateral parietal. See video.

This is for reference purposes only. Consent to photograph was obtained from the patient or family. EM:RAP and the authors assume no liability for use of the techniques described. Local practice, current guidelines, and clinician experience should determine the exact procedural process in any individual patient. © 2020 EM:RAP Inc.