a. Marking

b. Inject Local Anesthetic with Epinephrine

1. Surgical Approach

2. Incision

3. Dissection down to the Bone

4. Drill Hole

5. Bolt Placement

6. Hook Up Camino ICP Monitor

7. Suture and Dressing

8. Post-op Remarks

Intracranial hypertension is a critical concern in traumatic brain injury (TBI), with elevated intracranial pressure (ICP) significantly impacting patient outcomes.1 ICP monitoring is an essential component in managing patients with various brain pathologies that can lead to dangerously elevated intracranial pressure. In neurosurgical practice, accurate monitoring and timely intervention are critical when dealing with the challenges of intracranial hypertension, and its timely resolution is crucial for preventing severe neurological sequelae and fatal outcomes.

The risk of Infections or hemorrhage of significance associated with ICP devices, which can lead to patient morbidity, usually do not outweigh the benefit of continuous ICP monitoring in TBI. Therefore, these should not deter the decision to monitor ICP.

This video provides step-by-step visual guidance for placing a right frontal Camino bolt to guide optimal patient care. In this clinical case a patient presents without prior opportunity for clinical exam and with reported signs of a cranial hemorrhage, coupled with a right occipital fracture, thereby requiring ICP monitoring to proceed with further neurosurgical care.

<h4>CHAPTER 1</h4>

<p>A little bit lateral to that.
Lateral to that?
Yep, I'd go right there.
And then, here?
Yeah, I think right there.
And then, to that equivalency underneath that dot.
Yeah. So it's kind of like a stab incision,
but a little bit bigger.
And honestly, the uh,
the important thing is that you can see the skull,
and you can see your drill tip.
And then, there's no question that you're through the skull at the end.
So, this is closed.</p>

<h4>CHAPTER 2</h4>

<p>So, straight down to skull.
And then your goal - I know you've done this before,
but your goal here is to, you know,
get down quickly and then go - make sure
that you're basically not leaving a big dip, right?
So, down and then angle it and pull it up
and then go back and clean up that edge.
Yep. Cool.
All right. Go for it.
All right, we're making an incision here.
Right side. Right side.
Emergent right frontal bolt for ICP monitoring for
a GCS less than eight.
Incision.
Down bone incision. Incision.
Up the edge.
Over here, up on this side.</p>

<h4>CHAPTER 3</h4>

<p>All right, so - knife back. Knife back.
You can open that up
and make sure that you have -
you're down to the bone.
You need to...
Okay. Take the Weity - open it up.
So, yeah, exactly.
If you need more space, just open it more.
You mean with the knife?
Yeah.
That might be a little too small.
We don't want it to be too big
because we don't have to, like, place a stitch around it.
So, uh, just like ever so slightly...
A little more.
Yep. And then maybe the other way.
Ever so slightly.
Cool. All right.
Cool.
Um, yeah, so...
Uh, yeah, you're good.
Take that gauze.
Jam it in there.
Take the back end of that
and just like back and forth, back and forth.
Really broad strokes. Yep. You got it. Just like that.
Mm-hmm. Get rid of all the galea.
Yep.
That's our cranium.
All right, so now we're through.
We want a little bit more - so see,
if you can just go up a little bit.
All right.</p>

<h4>CHAPTER 4</h4>

<p>So we can see the skull. Okay, awesome.
All right, there you go.
All right. You're probably...
Move your hand up a little bit if you can.
There you go. Keep going.
You feel - through the first layer?
Yeah, I'm in the... Softer now?
Yeah, I'm in the soft.
Awesome. All right.
Should feel it catching soon. And now I'm encountering the
the inner table.
Okay, keep going, keep going, keep going.
All right, hold on. All right.
Let's see. Um...
All right, keep going.
All right, I think I'm at the thing. Start pulling out.
Start pulling, all right, perfect.
You think you're through?
Uh, I don't know.
All right, let's grab some suction.
Take a look.
Let me see that real quick.
I can't see the inner table,
so either it's not there or it's too dark.
You feel it?
All right, you still got a little ways to go.
All right.
Feel it.
All right.
Feel it?
Yeah, it's all the way through, it's all the way around.
Yeah.
Here you go.
Probably very close.
So, you know...
Now, let's make sure - uh, hold on.
Take this out for a second.
I'm just gonna do this.
Because otherwise you're gonna get stuck again.
All right, so careful. No plunging.
Here you go.
Otherwise it's gonna bump up against your Weity.
Up a little bit more.
Perfect.
All right? Yep.
And as soon as it catches, pull on back again.
Yeah, you're in, you're in, you're in, you're in, you're in.
All right.
Okay.
Let's…</p>

<h4>CHAPTER 5</h4>

<p>Uh, there you go.
Oh, sorry. Let's take these out.
Need me to pull out?
Uh, no, you're good.
I think it should be okay.
All right.
You want it to be pretty tight.
Any resistance?
A lot of resistance, yeah.
It might be okay.
Interesting.
Wow.
Is it tight?
Or the angle was wrong?
I'm not sure.
Let's see.
Through the dura?
Yeah, I think we're good.
Uh, like there is dura, or...
No, I think we're all the way through.
Through the dura. Yeah.
Although it's interesting, I don't see anything there, so...
But let's see if we can...
No.
Yeah, I think that's actually pretty good.
Okay. All right.</p>

<h4>CHAPTER 6</h4>

<p>Okay, so let's hook up the ICP monitor.
All right. You grab this.
Like, hold it with your life, don't drop it.
Okay.
Can you, Terrick, help us
plug this end in over here?
So take that.
- [Hsueh] All right. Just, don't let it go, okay?
Uh, turn it over. Yep.
There we go.
Okay, now...
All right.
That should come up over there.
And you might have to go through and say, uh,
settings.
And then, uh,
there's like a -
there's a - calibrate.
Oh, there we go. All right, we're good.
Uh, can you hold it a little bit closer here,
Terrick? Sorry.
Terrick, bring your hand a little closer to me.
So this is like super -
yeah, so you,
you're gonna need to put your other hand under here
because it takes a little pressure.
Uh, but like, just like, literally just like,
almost effort will change it, right?
Wrong way.
Yeah.
Like, you're almost not even turning it,
you're just, like, pretending to turn it
and waiting, like, 30 seconds, or five seconds.
Yeah, keep going. If that's the wrong way, then go
a little bit the same amount the other way.
All right. And like, oh...
I love it. All right.
Let's do it.
So...
So I'm gonna put this down.
So, now this goes in here, right?
And as soon as this is in -
when you're at - you don't want to actually push this in,
you just wanna seat this on here, all right?
Yep.
So, this is seated on here now.
Okay? Yeah.
Now you're gonna advance this,
until it's just past this line right here.
Yeah, keep going.
And tell me if you feel any pressure or resistance.
I'm, I'm hitting resistance right away.
Are you? Yeah.
All right, let me see.
It's feels like plastic.
Huh.
There we go.
Oh, okay.
It was caught on the lip a little bit.
All right.
So...
Nothing yet.
All right, now it's in.
All right, now go, just like a little bit past to like right here.
Here? All right, and now pull back.
Right there. Let's leave it.
Okay.
All right, and then tighten this pretty tight.
Need to tighten more?
Yeah. You don't wanna like break it off,
but like, pretty darn tight,
because otherwise it'll pull out.
Yeah, that's good.
All right.
Okay.
Uh, okay.
So this is good.
I don't know, if I really trust it. Um...
There's a waveform.
Is there a waveform?
Yeah, there's a waveform there.
All right then I trust it. Fantastic.
But uh, can we change the scale?
Can you press the scale button?
So let's get a - we'll dress it right now.
We'll get a stat CT head on the way to the ICU,
and make sure everything looks good at the placement here,
and there's no interval change in any of those bleeds.
It's non-con, right? Non-con. Exactly.
So... Excuse me - we have the scanner ready for it.
Okay. Yeah, so it's a little bit -
you know what? Uh... Do you wanna buzz?
Can we do it that close to the...
Yeah. So I would say, uh...
let's just throw...
Throw one stitch on each?
Let's throw one stitch on either side.
All right.
Uh... Monocryl, or...?
Let's do a nylon
because, regardless, we're gonna have to put something in
when we take it out. What size nylon?
Whatever. 3-0, 4-0, doesn't matter.</p>

<h4>CHAPTER 7</h4>

<p>Just a single interrupted.
In the anterior part?
Yeah, I think the posterior looks fine,
although I can't see really.
Yeah, posterior looks fine.
Cool. There's one over here.
And then...
Oh, you got it? Cool.
Cool, thank you
Also, thank you.
You already had the Tegaderms out.
Yeah. Uh...
And then, yeah, that's fine.
You want it way in there?
Yeah, exactly.
Like right up, right up in there.
And then you don't have to do this whole thing.
So, we'll just basically make the little unicorn,
and then, uh, cut it as soon as...
We're basically, sub-sterile at this point.
So we basically wanna be able to see the red, right?
Yeah, exactly.
And then we'll do the little, like, loop thing.
I don't even know about the loop thing, but it sounds good.
It's to prevent it from getting pulled out.
Oh, yeah, exactly. Yeah, yeah.
I just do Tegaderms around that,
so it's all clear.
Yea, so that's probably good.
Yeah, I think that's fine.
Do we have like a massive Tegaderm?
Uh, yeah. They already pulled the...
We have like just a bunch of little ones,
but if they have a bigger...
We're probably gonna need, like, a bunch more.
Do you want, like, a large, would that be...
Uh, this is fine.
Okay.
So, let's move this away.
Thank you.
Mm-hmm.
There's four more on that prep table.
Cool, thank you.
Yep. Is that enough?
Uh, yeah. Yeah, that'll - I think so.
Okay. I think so.
Just let me know. I have more.
Okay.
And we're good for CT head on the way over?
Yeah, I'll just call them on our way out.
Cool.
Okay, we're gonna get a scan on the way to the ICU?
What's up?
CT head on the way to the ICU? Exactly.
Okay. Continue mannitol, or stop it?
Uh, I don't think we need it with an ICP of one.
Good.
So, should be able to stop that.
I'm gonna stop it then.
Cool. Yeah, looks good.
They can see this.</p>

<h4>CHAPTER 8</h4>

<p>Nathan Sisterson, one of the neurosurgery PGY2s here.
Consult resident for today.
So we had a trauma come in with no exam
and reports of head bleed, right occipital fracture.
That's an indication for ICP monitoring,
especially since we don't have an exam,
and this patient was going emergently to the operating room.
We just now placed an ICP monitor -
an El Camino bolt system -
that is going to measure the ICPs
and make sure that there's no critical swelling
or bleed while we don't have an exam to
otherwise monitor the stability of this patient.
So, the procedure involves making a small incision
in the skin
and then a small burr hole through the skull
at Kocher's point,
10 cm back from midline from the nasion
and 3 cm over from midline.
I was working with one of the neurosurgery interns, Brian,
who placed the ICP monitor today.
He'll actually be doing that
independently of this time next year.
So it was training for him as well.
So, at that midpoint - incision, burr hole,
and then calibrate that ICP monitor,
and just place it slightly into the brain parenchyma,
confirm that we have a good wave form,
and now we're going for a stat CT head to confirm placement,
make sure that there's no bleed as a result
of the ICP monitor placement,
and then to make sure that there's no interval change
in the bleed in the head,
which is the reason we placed the monitor
in the first place.
From here on out, the ICP monitor will be used
to guide medical management, and if her ICPs go up,
there are medications we can give, you know,
Mannitol, 22% sodium, that will decrease the
ICPs, intracranial pressures,
and hopefully avoid a surgical intervention for her.</p>


Watch this full-length, narrated surgical video of a Camino bolt placement for ICP monitoring.

Massachusetts General Hospital