Intraosseous Needle for Craniotomy

This week, I would like to present a case study by Bulstrode et al (Injury, Int. J. Care Injured 48 (2017) 1098–1100) on the use of the EZ-IO drill for drainage of an extradural haemorrhage.

The case is of a 43 yo pedestrian hit by a car at low speed. The patient’s  GCS on arrival to the Emergency Department was 14. A CT Brain shows a small frontal contusion and an occipital extradural.

One hour later, the patient’s GCS deteriorated to 8 and the left pupil was fixed and dilated.

A repeat scan demonstrated a large occipital-parietal extradural with midline shift.

The patient was intubated and prepared for transport to a larger facility.

On arrival to the larger centre, the patient went to the operating room. Initially a 25mm 15 gauge intraosseous needle was used, after preparation of the occipital region, to aspirate 30ml of blood.

The patient then had a formal craniotomy and made an excellent recovery.

The procedure took about 8 minutes and did not delay the formal procedure, as the patient was being prepared at the same time.

This is the first time the I/O needle has been used for this purpose. It is perhaps a glimpse of the future for  rural emergency department specialists, where patients deteriorate and transport is hours away.

The procedure can have its downside, with a risk of hitting blood vessels and causing further bleeding estimated at about 3%. However remember, that patient is deteriorating and needs drainage. Waiting will kill them.

The Neurosurgical Society of Australia recommends burr holes. In my view this is a safer approach.

The appropriate training is a must, but it is procedure that we can perform in the emergency department, that can make a significant difference.

Peter Kas