Emergency Burr hole for an epidural hematoma: A case report

A burr hole is a high-acuity low-occurrence procedure that Emergency Physicians (EPs) must be familiar with in order to treat certain epidural and subdural hematomas in settings where neurosurgery is unavailable. A 32-year-old male presented to a community Emergency Department in a snowstorm after an All-Terrain Vehicle (ATV) accident with a headache, rib pain, and facial lacerations. He was found to be neurologically intact initially. Computed tomography (CT) imaging revealed a large epidural hematoma (EDH) with midline shift. The patient then had a significant change in mental status. Tertiary care centers and transportation teams were contacted, but due to the weather the patient could not be transferred for an estimated 5 h. An emergent burr hole was completed in the Emergency Department (ED), and he was transferred when it was safe by ground. He underwent surgical evacuation and he does not have any neurologic deficits today. This case portrays the importance of EPs being familiar with performing a burr hole although it is not a required Accreditation Council for Graduate Medical Education (ACGME) skill that Emergency Medicine (EM) residents are specifically trained on. It is vital that EPs know the indications for the procedure in the ED, the resources available at specific hospitals to assist, and the equipment needed to perform a burr hole. Performing an emergent burr hole when neurosurgery is unavailable in rural settings is sometimes necessary. It has been shown to be related to good outcomes for patients and this case serves as an example.