title: Emergency department skull trephination for epidural hematoma in patients who are awake but deteriorate rapidly.
abstract: BACKGROUND
  Blunt head trauma patients who have been alert but are deteriorating (talk and deteriorate [T&D]) due to a rapidly expanding epidural hematoma (EDH) usually have poor outcome if they must wait for hospital transfer for evacuation. We therefore have continued to teach skull trephination to emergency physicians (EPs). We are unaware of any literature on EP trephination for EDH in the age of computed tomography (CT) scanning.
  
  
  METHODS
  Patients with EDH from blunt trauma, either in our institution or known to our graduate network, who were T&D with anisocoria despite intubation plus medical therapy, and who had pre-transfer EP trephination, were compared to those who were transferred without trephination.
  
  
  RESULTS
  There were 5 patients with blunt trauma and CT-proven EDH who were T&D with anisocoria who underwent Emergency Department (ED) trephination at outlying hospitals before transfer. All 5 had improvement in condition and good outcomes. Three had complete recovery without disability and 2 others had mild disability with good cognitive function. None had complications. Two patients with T&D and anisocoria were transferred without trephination. Both had good neurologic outcomes. The mean time to pressure relief in the trephination group vs. transfer group was 55 vs. 207 min, respectively.
  
  
  CONCLUSIONS
  In T&D patients with CT-proven EDH and anisocoria, ED skull trephination before transfer resulted in uniformly good outcomes without complications. Time to relief of intracranial pressure was significantly shorter with trephination. Neurologic outcomes were not different.
authors.affiliation: Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA.
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Smith
authors.forename: Michael
authors.initials: M
authors.lastname: Clark
authors.forename: Jody
authors.initials: J
authors.lastname: Nelson
authors.forename: William
authors.initials: W
authors.lastname: Heegaard
authors.forename: Kirk C
authors.initials: KC
authors.lastname: Lufkin
authors.forename: Ernest
authors.initials: E
authors.lastname: Ruiz
mesh_terms: D000328:Adult; D000368:Aged; D006259:Craniocerebral Trauma / Q000150:complications* / Q000000981:diagnostic imaging; D004636:Emergency Service, Hospital; D006407:Hematoma, Epidural, Cranial / Q000000981:diagnostic imaging / Q000209:etiology* / Q000601:surgery*; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014207:Trephining / Q000379:methods*