Having been there and done it both in a past life as a drain surgeon and
since, when we had a similar event on the scanner in a 10 year old, here,
90 mins road time from the nearest drain surgery unit, I phoned them told
them what I was doing, they said go for it, but I had the advantage of
being friendly with them, I performed a craniectomy since the extradural
has the consistency of blackcurrent jam and does not flow but has to be
scraped out or sucked out.
If you must do it, start with a burr hole over the fracture if one is
present and then nibble bone away until you reach the edge (in principle.
Normaly the blood comes from a surface vessel on the dura. A stitch or
diathermy will teach it a lesson.
The pressure is now off and the rest requires a bit of fiddling and is best
left with the experts
It is rare to need to do this. Most Intracranial clots are SDH (5:1)and
have a slower time scale. Only needed in the rapidly decompensating EDH a
long way from the drain surgeons. I have done this once in 6 years as an
A&E consultant and we see a fair number of head cases, and I chose to go to
a remote unit in the selfish hope that some of my previous training might
come in useful!
ps the ambulance broke down during the transfer post op and took 3 hours.
The girl survived with not too much persistent neurology.
>OK, let me explain my thought process.
>
>Hyperventilation to PCO2 between 25-30 will decrease ICP but peaks at 8
>minutes and is only effective in the acute phase. I don't think it will
buy enough
>time for the patient to be transported to a hospital 30 miles away. It may
>even give you a false sense of security as the patient is leaving your
facility.
>I don't know how this correlates to a "CO2" but if you mean the partial
>pressure of carbon dioxide, it should not fall below 25 as you are at risk
of
>causing profound vasoconstriction and ischemia to both normal and injured
areas of
>the brain.
>
>I agree that mannitol should be given, and if improvement in the first few
>minutes then maybe there is no need for burr hole. It will, given it's
longer
>duration of action buy the patient her transport time. However given the
>scenario I doubt she will reap enough benefit. In addition, the decreased
ICP
>secondary to Mannitol may cause loss of tamponade and allow more bleeding
to occur.
>
>I am not suggesting several burr holes or a craniotomy be performed in the
>emergency department. We know where the blood has accumulated. The patient
will
>need a craniotomy regardless of whether she receives a burr hole in the ED
or
>not, IF she makes it to the neurosurgeon alive, which is our goal.
>
>So, while contacting an ambulance and the neurosurgeon and while ordering
the
>mannitol I would also prepare to perform a burr hole on this patient. If
she
>did not show rapid improvement after the mannitol I would rather her die
>having attempted a potential lifesaving procedure in my care than have her
die
>without one.
>
>Renee
>
>
>
>
>
>
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