Some of you are probably asking yourselves why we would even bother reviewing this procedure. While this may seem like the purview of neurosurgery alone, technically EM physicians can (and have) done them. It goes without saying that this will not be something that you are doing routinely. If you are considering doing burr holes as an EM physician, something has probably gone horribly wrong, and/or you are at a remote critical access hospital with no way of getting your actively decompensating patient to definitive care.

Burr holes are done on patients with epidural or subdural bleeds. There is no benefit to this type of cranial decompression for patients with intraparenchymal, intraventricular, or subarachnoid hemorrhages. This may seem obvious but is still worth saying: you must have some kind of imaging that shows the type of bleed, location of the bleed, and the area of maximal depth to appropriately position where you put the burr holes. Get that CT and personally look at it ASAP. You should still discuss the patient and your plan to do burr holes with a neurosurgeon, preferably one who will take care of the patient once you are able to get them transferred. If you have the ability, a video chat with the surgeon while you are doing the procedure can also be helpful.

While this procedure is intimidating, just remember that skull trephination has been done for thousands of years by humans without imaging or advanced procedural skills. Not saying you should use medieval techniques, but I know you can do better than someone from the 1400s.

The Extraction of the Stone of Madness

-Hieronymus Bosch

Don’t be this guy – don’t do burr holes out on a patio with an oil funnel on your head.

Indications:

Patient with a CT proven epidural or subdural hematoma with midline shift who deteriorated with exam findings suggestive of herniation - drop in GCS, unequal pupils, posturing, hemodynamic changes consistent with the Cushing triad (sudden hypertension, bradycardia, and slow/irregular breathing)
Known epidural/subdural with GCS <8

Either of the above AND

No neurosurgeon or surgeon available in a reasonable time frame (probably the most important reason)
- Best outcomes are seen if the herniation is relieved within 60 min

Contraindications:

No absolute contraindication as this is generally done as an immediately lifesaving procedure
Relative may be coagulopathy – correct coagulopathy/reverse blood thinners prior to drilling
- Do not immediately reverse thinners if the patient has an LVAD - discuss with cardiology and neurosurgery first

Considerations with Consent:

This is likely going to be a very emergent procedure in an altered and decompensating patient
Risks:
- Pain, bleeding, infection – meningitis/cerebritis/intracranial abscess, brain damage with neurologic deficit, stroke, seizure, need for repeat procedure and/or failure of procedure, death
Alternatives:
- Medical management with hypertonic saline/mannitol/Lasix

What you will need:

Razors
Surgical skin marker
Ruler
Lidocaine with epi
A few 5 or 10 ml syringes – for lido and sterile saline
25 ga needle
Chlorhexidine or iodine
Sterile towels and drape
Scalpel
Mosquito forceps – think very small hemostats

Mosquito or other tiny scissors
Alligator forceps – to pick up the dura if needed

Self retaining retractor to expose the scalp – sometimes can be found in surgical cric kits

Hand drill - may look something like this

Perforating drill bit – will need to be relatively short to avoid going too deep

Lots of 4x4 gauze
Sterile gown
Mask/hat
Sterile saline
Stapler
Drain of some sort – penrose, red rubber
An assistant

How to do it:

Make sure you have a secure airway (if indicated) and your patient is hemodynamically stabilized before starting
Get imaging to confirm the location and type of bleed
- If patient has had decompensation, repeat head CT to find area of greatest accumulation to try to drain
- Measure the skull thickness on the CT – some drills have stoppers that can be set to match the skull thickness to help prevent drilling into the brain parenchyma

Discuss with neurosurgery prior to making decision to attempt ED burr holes
The location of the burr hole depends on the location of the bleed
- IF you are unsure, use the temporal site
- DO NOT drill into or near a skull fracture – you can push bone fragments into the brain, which is suboptimal
- Temporal- 2 finger-breadths above and 2 finger-breadths forward of the auditory canal
- Parietal- over parietal eminence – the widest part of the skull where the parietal bone forms a small hill

- - Frontal- 10 cm above eye in mid-pupillary line (about 3 cm lateral to the sagittal suture)

Shave the scalp widely over the selected site, can use skin marker to mark landmarks and intended burr hole location
Patient should be positioned supine
Cleanse skin well with chlorhexidine or betadine/iodine
Anesthetize the skin and soft tissue with lido + epi – will help some with scalp bleeding
- You will be making a larger incision so be generous
Drape in sterile fashion with surgical towels and/or sterile drape
Open necessary supplies onto sterile field
Set up drill – place bit
- Set the appropriate depth based on the skull thickness from the CT (if the drill can do this). Some drills will have a stopper – this can be placed on the drill bit to prevent the bit from going too deep
Make a 3-5 cm incision into the scalp and dissect down to bone
- The scalp bleeds quite a bit – you can hold pressure on the incision edges or use electrocautery (one of the cordless cautery devices used for nail trephination could work if needed)
Carefully dissect/peel the periosteum off the skull with the scalpel
Use the self-retaining retractors to hold the area open – if you don’t have retractors, have an assistant hold the area open
Have your assistant firmly hold the head steady
Place the drill onto the exposed bone at a 90-degree angle and apply gentle continuous pressure while hand cranking the drill
- You may encounter bone shards – an assistant can use a syringe to squirt saline on the drill/drilling site to clear away
Continue drilling while applying pressure until there is a loss of resistance (or the drill stops spinning in the case of certain drills)
Gently remove any remaining skull fragments
- Skull pieces can be preserved in a sterile cup with sterile saline
If the bleed is epidural, you should have an immediate return of blood from the burr hole
If the bleed is subdural, you will need to very gently elevate the dural membrane (use the alligator forceps) and carefully incise with the scalpel or a very small scissors
Allow blood to drain freely, do not suction as you can inadvertently suction onto the brain itself
Once drainage has slowed, remove retractor
Place drain under scalp and then loosely staple scalp back together with drain tubing sticking out to allow continued decompression of the bleed
Cover the area loosely with gauze/tape.
- No not use occlusive or pressure dressings  want blood to continue to drain
Post procedure
- Give dose of ceftriaxone or some other antibiotic with CNS penetration to cover broadly for skin flora
- Transfer patient ASAP for definitive surgical management

Alternative methods

There are multiple case reports of this being done with an IO drill
Use a BLUE needle (25 mm) unless the skull is very thin
- Do not use too short of a needle – the needle needs to be in far enough to go through the skull and extend into the bleed

Similar to an open procedure:
- Shave the scalp
- Clean with chlorhexidine/betadine
- Anesthetize the area with lidocaine
- Place the IO in the usual fashion
  - Stop drilling immediately on loss of resistance
- Remove twist off internal trochar
  - Ideally blood will return immediately, can attach the pigtail tubing with the IO needle and use syringe to apply very gentle suction
- Stabilize the IO needle – tape two rolls of kerlix on either side of the needle to stabilize. Leave the pigtail in place, do not leave the needle open to air
- Give dose of ceftriaxone or some other antibiotic with CNS penetration to cover broadly for skin flora
- Transfer ASAP
- If the patient has evidence of herniation or increased ICP again, consider draining additional blood from the IO needle or place a formal burr hole

A few additional points:

This should only be done if there truly is no neurosurgical backup, and the patient cannot be quickly transferred BUT do not delay procedure if indicated
Generally, should be done in combination with medical management
- 3% NaCl bolus 250-500 ml
  - Sodium bicarb is alternative – give three 50 ml amps of the 8.4% (code concentration bicarbonate)
- Mannitol 0.25 g/kg over 15 minutes, can be repeated up to 1g/kg
  - Will cause huge osmotic diuresis, can make patient hypotensive from fluid shifts
- Lasix IV as adjunct to hypertonic saline/mannitol
- Be aware that the patients getting mannitol and/or Lasix will put out a significant amount of urine, very fast, and may get hypotensive
If you are going to do a burr hole, the sooner it is done, the better. Clotted blood will be much harder to evacuate through a burr hole (or IO needle)
If the patient continues to decompensate neurologically and repeat imaging shows persistent epi or subdural hemorrhage, you may need to place additional burr hole(s) – start with a burr hole in the temporal site on the contralateral side, and if needed, a third hole over the temporal area on the ipsilateral side (or frontal/parietal if there is a hole in the temporal area already)

Relevant Billing/CPT Codes:

61154: Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural.
61156: Burr hole(s) with aspiration of hematoma or cyst, intracerebral.

61108: Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drain.

References:

https://pmc.ncbi.nlm.nih.gov/articles/PMC3352313/ - this is an amazing reference paper
https://www.emdocs.net/unlocking-common-ed-procedures-crackin-the-cranium-a-review-of-cranial-burr-hole-decompression/
https://www.acepnow.com/article/perform-emergency-burr-hole-procedure/
Howard A, Krishnan V, Lane G, Caird J. Cranial burr holes in the emergency department: to drill or not to drill?.Emerg Med J. 2020;37(3):151-153. doi:10.1136/emermed-2019-208943
Heran N, Yan TD, Heran MKS, Behboudi A, Kadyschuk SK. Intraosseous needle for management of subacute and chronic subdural hematoma.J Neurosurg. 2025;143(3):846-853. Published 2025 May 2. doi:10.3171/2025.1.JNS241265

Videos:

https://www.youtube.com/watch?v=QeDQZoeg0RA – really good video
https://www.youtube.com/watch?v=8C5ukUi-WQQ – (ignore the weird visual of the resident telling a story about palm trees while poking at a duct taped head) talks about alternative locations if initial burr hole was not adequate
https://www.youtube.com/watch?v=ZV3ZxiCm2n0 – great video but weird voice over. Shows the use of saline and a cautery device. You can see how the blood will come out under some pressure. They were probably far too aggressive with the suction catheter and sticking things into the burr hole – not recommended.
https://sjtrem.biomedcentral.com/articles/10.1186/1757-7241-20-24 - very good step-by-step paper
https://emcrit.org/wp-content/uploads/2012/08/RM_Burr_Hole.pdf - another good paper with lots of pictures