Procedure Talk: the Bier Block
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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!
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?
Sedation and
analgesia
Axillary block
Hematoma block
Bier block
Red Flags
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
PROs
great for anxiety
and pain relief
CONs
NPO status
Wheezing
Small mouth
Axillary block
PROs
great for
prolonged pain
relief
CONs
painful procedure
obese habitus
apprehensive
child
Hematoma block
PROs
great for pain
relief
CONs
apprehensive
child
Bier block
NO. IT HAS
NOTHING TO DO
WITH THIS.
Bier block
IV regional
anesthesia
August Bier, 1908
Modern version,
1970s
Preparation
Anxiolysis
Muscle spasm
Uncooperative
patient
IV in affected
extremity
Procedure
Exsanguination
Tourniquet
Pneumatic cuff to 250
mm Hg in arm or 50 mm
Hg > SBP
Medicine
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
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
Bier block: CONs
Lose pulse
Possible superficial nerve damage
Unable to splint or cast with tourniquet
inflated
Bier block: Adverse Events
Tourniquet pain
At IV site: blotchy erythema, flushing,
urticaria
Dizziness, metallic taste in mouth,
tingling
Tourniquet fails Lidocaine bolus:
Headache, lethargy, slurred speech, seizure
Hypotension, bradycardia
Bier block: Contraindications
Shock
Multiple trauma
Hypersensitivity to lidocaine
Seizure disorder
Sickle cell disease
Bier Block: Controversies
Dose of lidocaine
Volume of lidocaine infusion
Other meds
Instead of lidocaine
In addition to lidocaine
Bier block: Indications
Closed fractures
Burn debridement
Removal of ground-in debris
Abscess I&D
Laceration repair
Foreign body removal
Limited surgical procedures
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.