Transcript Procedure Talk: the Bier Block

Procedure Talk:
the Bier Block
John Cheng, MD
PEM Fellows Conference
Emory University School of Medicine
CHOA at Egleston and Hughes Spalding
May 24, 2006
Case: Owee!
7 y/o boy was riding his bike home from a birthday
party and fell off trying to make a turn. He fell,
arms outstretched. No LOC.
ROS: cough x 3 days
PMH: asthma, 3 admissions
for asthma
Med: Advair, Albuterol MDI
Allergies: eggs
Case: Owee!
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General: morbidly obese
boy sitting on stretcher with
T-shirt covered in cake icing
and punch stains;
apprehensive; holding left
arm in pain
ENT: small mouth and chin
CV: tachycardic, otherwise
normal
Pulm: expiratory wheezes,
good air entry, no retractions
Abd: soft, NT/ND, nl BS
MS: left forearm with
obvious deformity, +2
pulses, <2 sec cap refill,
moves fingers, sensation
grossly intact
Options?
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Sedation and
analgesia
Axillary block
Hematoma block
Bier block
Red Flags
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General: morbidly obese
boy sitting on stretcher with
T-shirt covered in cake icing
and punch stains;
apprehensive; holding left
arm in pain
ENT: small mouth and chin
CV: tachycardic, otherwise
normal
Pulm: expiratory wheezes,
good air entry, no retractions
Abd: soft, NT/ND, nl BS
MS: left forearm with
obvious deformity, +2
pulses, <2 sec cap refill,
moves fingers, sensation
grossly intact
Sedation and analgesia
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PROs
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great for anxiety
and pain relief
CONs
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NPO status
Wheezing
Small mouth
Axillary block
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PROs
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great for
prolonged pain
relief
CONs
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painful procedure
obese habitus
apprehensive
child
Hematoma block
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PROs
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great for pain
relief
CONs
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apprehensive
child
Bier block
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NO. IT HAS
NOTHING TO DO
WITH THIS.
Bier block
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IV regional
anesthesia
August Bier, 1908
Modern version,
1970s
Preparation
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Anxiolysis
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Muscle spasm
Uncooperative
patient
IV in affected
extremity
Procedure
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Exsanguination
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Tourniquet
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Pneumatic cuff to 250
mm Hg in arm or 50 mm
Hg > SBP
Medicine
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Gravity or compression
with bandage
Lidocaine 1.5-3 mg/kg
over a minute
0.33% Lidocaine 3
mg/kg
Procedure after 3-6
minutes
Post-procedure
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Deflate for a few
seconds
Re-inflate for a
minute
Rinse, lather, and
repeat
Observe for 15
minutes
Discharge
Bier block: PROs
No need for NPO status
 Pt is awake during procedure.
 Shorter post-procedural observation
time
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Bier block: CONs
Lose pulse
 Possible superficial nerve damage
 Unable to splint or cast with tourniquet
inflated
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Bier block: Adverse Events
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Tourniquet pain
At IV site: blotchy erythema, flushing,
urticaria
Dizziness, metallic taste in mouth,
tingling
Tourniquet fails  Lidocaine bolus:
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Headache, lethargy, slurred speech, seizure
Hypotension, bradycardia
Bier block: Contraindications
Shock
 Multiple trauma
 Hypersensitivity to lidocaine
 Seizure disorder
 Sickle cell disease
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Bier Block: Controversies
Dose of lidocaine
 Volume of lidocaine infusion
 Other meds
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Instead of lidocaine
 In addition to lidocaine
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Bier block: Indications
Closed fractures
 Burn debridement
 Removal of ground-in debris
 Abscess I&D
 Laceration repair
 Foreign body removal
 Limited surgical procedures
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Summary
There are many ways to provide
analgesia for fracture reduction.
 Bier blocks have their own set of risks,
but no more so than sedation &
analgesia.
 Bier blocks are an effective way to
reduce forearm fractures with minimal
discomfort.
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