Written by Gabby Leonard
The EZ-IO may be considered as a temporizing measure for trepanation of an epidural hematoma (EDH) in rural ED settings. This should be considered only under the guidance of a skilled neurosurgeon when immediate transportation to a higher level of care is not possible.
Why does this matter?
EDHs comprise up to 4% of admissions for pediatric patients presenting with closed head injuries and carry a 5% mortality rate, compared to 4% of adult head injuries with a 10% mortality rate. Early evacuation (within 1-2 hours) of post-traumatic EDH reduces mortality from 56% to 17% when compared to delayed or untreated bleeds.
An EDH classically presents as loss of consciousness after blunt head trauma followed by a lucid interval and then rapid neurologic deterioration. It is typically due to arterial bleeding from the middle meningeal artery. This is a neurologic emergency due to potential for elevated intracranial pressure and potential for herniation that requires prompt treatment by a neurosurgeon, typically involving decompressive craniotomy or trepanation via burr hole.
This article reviews the case of a 17-year-old female who had a delayed presentation to a rural ED with closed head injury after a MVC. She was found to have an EDH and ultimately required intubation due to declining mental status. There was a delay in transfer to a facility with pediatric neurosurgery due to weather, so the emergency physician used a 25mm 15-gauge EZ-IO to drain her EDH, under guidance of a pediatric neurosurgeon. The patient was safely transported to a level 1 pediatric trauma surgeon where the remaining hematoma was evacuated, and the patient made a full neurologic recovery.
While this sounds promising, similar case reports have had mixed outcomes; per my review, the larger the bleed and older the patient, the less likely it is for the patient to survive after IO-evacuation.
Editor’s note: This should not be considered standard of care. In fact, there are very few scenarios in which this would be indicated. However, in a dire situation, it could save a life, which is why I thought we should cover it. ~Clay Smith
Complete Neurological Recovery After Emergency Burr Hole Placement Utilizing EZ-IO® for Epidural Hematoma. J Emerg Med. 2022 Oct 10;S0736-4679(22)00354-7. doi: 10.1016/j.jemermed.2022.06.012. Online ahead of print.