Craniotomy/Burr hole

Craniotomy/burr-hole
1. Medical considerations –
a. Rapid sequence intubation if GCS 9 or less (E4V5M6), etomidate (0.3mg/kg IV) or thiopental (50 to 100 mg IV or 3 to 5 mg/kg) for sedation, paralysis with succinylcholine at 1.5 mg/kg (2 mg/kg in pediatric patients) and Fentanyl (3 µg/kg) for analgesia
b. Aggressive hyperventilation is no longer recommended (can cause cerebral vasoconstriction). Current recommendations state that target pCO2 to be 35-40mmHg.
c. Head elevation to about 30° in order to decrease ICP
d. Fluid restriction for patients with increased ICP is no longer in favor. Cardiac pressors, in addition to fluids, are often used to maintain CPP >70 mm Hg and MAP >90 mm Hg.
e. If increased ICP causes further deterioration in the patient's status, Mannitol can be given at 0.5 to 1.0 g/kg infused every 2 to 6 hours.
f. Seizure prophylaxis with Lorazepam, Diazepam, Phenobarbital or Phenytoin. No studies support the use of steroids in head-injured patients.
2. Adequate pre-operative preparation including bloods, crossmatch, IDC, AB prophylaxis, consent etc.
3. Shave entire scalp, position on head ring and prep/drape
4. Make a vertical incision (starting 2cm above and anterior to tragus, above the zygomatic arch) on the side of haematoma measuring 3-4cm and using a scalpel dissect down to outer table of temporal bone.
5. Insert self-retaining retractor to hold skin, temporalis, pericranium after elevation with periosteal elevator. Use Leroy-Rainey clips to stop bleeding from scalp edges
6. Use powered drill/burr or Hudson to make a burr-hole through outer table until a small window is made in inner table, then gently complete hole and apply bone wax to bone edges if bleeding.
7. Suck out extra-dural haematoma with ENT sucker, examine dura for subdural blood (often small insignificant amount) and incise dura carefully if suspect.
8. If no haematoma is found place further incisions over parietal and frontal bones for additional burr-holes in such a way as to be able to fashion a question mark type scalp flap if need to complete a craniotomy. Stay away (2cm) from the midline superior sagittal sinus
9. No need to close burr-hole but need to close dura with vicryl/temporalis fascia flap and replace bone flap if craniotomy performed and secure with stainless steel wire or plates
10. Consider ICP monitoring drain
11. Place subgaleal/extradural suction drains.
12. Repair Galea with vicryl and skin with staples.