Episode 976: Improvised Burr Hole in an Epidural Hematoma
Sep 29, 2025
A dramatic case unfolds as a 17-year-old girl suffers a severe epidural hematoma after a car crash. Rapid decompensation leads to urgent intervention when traditional tools aren't available. Ingeniously, an Intraosseous drill is repurposed to create a burr hole, resulting in immediate improvement in her condition. The discussion highlights critical insights on the importance of timely evacuation of hematomas to improve survival rates. Listeners gain practical advice tailored for rural emergency departments facing such challenges.
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Rapid IO Burr Hole Saved A Teen
A 17-year-old post-MVC patient at a rural ED acutely decompensated with a 1.5 cm epidural and 7 mm midline shift.
The team used an IO drill as an improvised burr hole, drained 35 mL, and her GCS rose from 3 to 8 with full recovery after definitive care.
volunteer_activism ADVICE
Drain If Transfer Exceeds Two Hours
If transfer to definitive neurosurgery will take longer than two hours, consider urgent local evacuation after neurosurgical consultation.
Review CT slices closely to map skull thickness and avoid sinuses or orbit before making an entry point.
volunteer_activism ADVICE
Map The Skull Carefully Before Entry
Measure skull thickness and localize the hematoma on CT before attempting any cranial entry.
Mark, prep sterile, and avoid frontal sinuses or orbit when selecting the burr site.
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A 17-year-old female involved in a motor vehicle collision presented to a rural emergency facility via personally operated vehicle. During workup and initial CT scan, the patient began rapidly decompensating with CT revealing a 1.5cm epidural hematoma with 7mm of midline shift. The patient went from being able to walk and talk to being obtunded with a blown left pupil and unresponsive. Following intubation, the patient was being prepared for transport but potential delays required immediate emergency evacuation of the hematoma via a Burr Hole. A traditional Burr Drill was not immediately available at the facility, so an improvised Burr Drill using an Intraosseous (IO) drill was used. 35mL of blood was removed from the hematoma and the patient immediately improved from a GCS of 3 to GCS of 8. The patient was transferred to a higher level of care facility, extubated the following day, and made a full neurological recovery.
Educational Pearls:
What is an epidural hematoma?
An epidural hematoma is a collection of blood between the dura mater (outermost layer of the meninges) and the skull, whereas a subdural hematoma is a collection of blood between the dura mater and arachnoid mater. Both can be life threatening depending on location and size.
Epidural hematomas tend to be arterial, and are typically secondary to trauma and can rapidly expand, but with timely recognition and evacuation of the bleed, favorable outcomes are often possible.
What are typical intracranial pressures and at what levels do they become pathologic?
Typical intracranial pressure (ICP) varies by age, but past infancy and early childhood, adolescents and adults have a value typically between 8-15mmHg. Values exceeding 20mmHg become pathologic and rise exponentially with increased volume.
Initial symptoms may include headache, nausea, and vomiting, but with increased pressures may progress to more life threatening symptoms such as loss of consciousness, cranial nerve palsies, pupillary constriction or dilation (sign of herniation), and respiratory irregularities.
What is the takeaway in timing of epidural hematomas?
Older studies show that evacuation of a hematoma with lateralizing features before the two hour mark of coma symptom onset is correlated with decreased mortality (ranging from 15-17%), but beyond 2 hours the mortality increases to well over 50%.
Though mortality statistics have grown more variable, early targeted evacuation of epidural hematomas still remains critical for improved patient outcomes. In austere conditions with limited resources, improvisation with interosseous drills and needles can improve patient outcomes and achieve the target therapy for epidural hematomas.
References
Haselsberger K, Pucher R, Auer LM. Prognosis after acute subdural or epidural haemorrhage. Acta Neurochir (Wien). 1988;90(3-4):111-116. doi:10.1007/BF01560563
Hawryluk GWJ, Nielson JL, Huie JR, et al. Analysis of Normal High-Frequency Intracranial Pressure Values and Treatment Threshold in Neurocritical Care Patients: Insights into Normal Values and a Potential Treatment Threshold. JAMA Neurol. 2020;77(9):1150-1158. doi:10.1001/jamaneurol.2020.1310
Pisică D, Volovici V, Yue JK, et al. Clinical and Imaging Characteristics, Care Pathways, and Outcomes of Traumatic Epidural Hematomas: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Study. Neurosurgery. 2024;95(5):986-999. doi:10.1227/neu.0000000000002982
Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan and Jorge Chalit, OMS4
Emergency Medical Minute