A staple of trauma and vascular neurosurgery.
Medications
10 dex
2g Keppra
1 mg/kg mannitol (confirm w/ attending)
+/- HTS
Preparation
- Bump (cylinder foam, blanket)
- Clipper
- Adhesive remover to get EEG leads off, you may think you’re saving time ripping them off, but then you’re just wasting more time scrubbing off the residual gunk
- Blue towels for under horseshoe (I dislike putting head directly on horseshoes)
- Xeroform for ears
- Tegaderm for eyes
- Iodine scrub brush
- Foley if does not add extra time
Incision & Draping
- Draw dotted line over midline (sinus)
- Reverse question mark incision
- Draping
- midline enough to show dotted sinus line
- posterior enough for a drain posterior-occipitally
Decompression
4 Burr Holes: each burr-hole should be thoughtfully maximized
- Keyhole (pterional): decompresses anterior temporal pole / frontal
- Root of zygoma / squamous temporal bone: decompresses midbrain (imperative to prevent uncal herniation)
- Frontal: right behind midline
- Parietal: defines posterior limit - take it to lamboid suture
- Drill with footplate drill: maximize your incision to connect outer parts of all burr holes, don’t be scared to go too wide
- If needed, Leksell down to the floor of the middle temporal fossa below Burr Hole #2
- counterintuitively, the bigger Leksell (not needle-nosed) is in general better and allows you to take tougher bites with less force
- Brain Trauma Foundation recommends 12 x 15 cm DHCs in latest TBI guidelines
Expansile Duraplasty
- make a giant cruciate duraplasty
Closure
- Change your gloves
- Ask for: 3x staplers, copious irrigation,
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