Burr Hole / Subdural Hematoma Evacuation
Patient phenotype
Chronic subdural: elderly (60s-90s) with falls, on AC, often dementia. Acute subdural: trauma, often poor neuro grade. Epidural: lucid interval after head trauma.
Procedure
1-2 burr holes through skull, dura opened, hematoma evacuated, drain placed. ~30-60 min for chronic; longer + craniotomy for acute. Supine.
Anesthetic plan
GETA. RSI if AMS or full stomach. Smooth induction. ICP control. Anticoagulation reversal if applicable.
Setup
- ·Standard + temp
- ·PIV
- ·A-line if hemodynamically borderline or known cardiac
- ·Mannitol available
- ·Reversal agents: vitamin K, PCC, idarucizumab, andexanet alfa per drug
Biggest concerns by phase
Anticoagulation reversal
Warfarin: vitamin K + PCC (KCentra). Dabigatran: idarucizumab. Factor Xa: andexanet alfa or 4F-PCC. DAPT: platelets if bleeding/expanding. Time critical for emergent.
ICP-conscious induction
Avoid HTN spike (rebleed). Pretreat with fentanyl + lidocaine. Mannitol if ICP elevated. Ventilate to PaCO₂ 30-35.
Sudden ICP drop after evacuation
Hematoma removal → CPP changes → BP swings. Maintain MAP for cerebral perfusion (especially with prior raised ICP — autoregulation reset).
Neuro check + ICU disposition
Document neuro pre + post. Most go to ICU intubated for 24h. Some chronic subdurals extubate.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
85-yo M, AF on apixaban, fall 2 wks ago, now confusion + R hemiparesis, CT shows L chronic subdural with 12 mm midline shift. Burr holes. Plan?
What an examiner probes for
- ▹Andexanet or 4F-PCC reversal
- ▹RSI for AMS
- ▹ICP-conscious induction
- ▹Mannitol
- ▹ICU postop
Sources
- Cottrell Neuroanesthesia 6e
- Neurocritical Care Society Reversal Guidelines
Anatomy reference
Sourced reference images. 4 matches for "brain skull dura".
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