Expanding epidural and subdural hematomas present a challenge for the docs working in rural or smaller hospitals. Most of us don’t have the training or equipment to perform the potentially lifesaving decompression. An article in Scandinavian Journal of Trauma, Resuscitation and Emergency medicine describes a simple procedure for evacuating extra-axial intracranial hematomas.
Many of us work in rural settings or in mid-tier hospitals without immediate neurosurgical cover. In the mid-level hospitals I worked in or retrieved patients from, most surgeons and orthos will refuse to decompress life-threatening extradural bleeds. They either lack the training or equipment.
So, our protocol instead of decompression is to send the scans, call the neurosurgeon registrar on-call at the receiving top-tier hospital, make the deal and arrange the transfer by helicopter or road ambulance.
Every time we get bogged down in a disappointing cluster-f**k of phone-calls, please-hold-the-lines, waiting for regs to call their consultants, waiting for them to call back, call the retrieval services, request the transfer and waiting for retrieval services to set the whole thing up. And then theres is 60 minutes flight time to the top-tier hospital.
Expanding extradural bleeds are time critical
All the above take time, and time is something these patients don’t have. I am pretty sure none of my patients have ever been decompressed within three to six hours.
In the STJEM article the authors reference a study demonstrating how one UK neurosurgical centre had average emergency transfer times of 5-6 hours for patients with deteriorating extradural or subdural hematomas. I have no reason to believe things can be expedited any faster in the places I worked.
This is certainly not good enough. We know expanding epidural hematomas can be as time critical as it gets.
Among the STJEM article references there is this one study from 1979 by Karmi et al, that tells us how dramatically time to intervention affects survival. The figure and diagram on the right came from that study. The outcomes are classified as:
O – OK
A – slightly disabled
B – Disabled but independent
C – Disabled and independent
D – Death
Delay is defined as time from first recorded reduced LOC to operation. The numbers nicely demonstrate how much there is to gain by early decompression or timely transfer. It would seem a delay around 2 hours is where it gets critical.
So what’s the point?
Extradural hematomas with a mass effect and a deteriorating patient needs to be drained within 1-2 hours. No retrieval system I am aware of manages that. So, shouldn’t emergency burr holes be a mandatory addition to the skill-sets of surgeons working in lower tier hospitals?
That could be difficult to achieve. It would mean having to train a very large group of doctors, with great variation in experience, who frequently rotate out of the region, to perform a rare and potentially dangerous procedure. A more reliable system would be to teach the much smaller group of retrieval physicians covering a region how to do it. These docs are coming to transfer the patient anyway.
I am guessing that is on the authors’ agenda. As far as I understand they are all associated with London HEMS.
No matter who eventually does it, it would require carefully defined indications and a carefully described standard operating procedure. The article in SJTREM does just that, the authors present an easy to follow, step-by-step procedure with reasonable and clear indications/contraindications.