Procedure Talk: the Bier Block

John Cheng, MDPEM Fellows ConferenceEmory University School of MedicineCHOA at Egleston and Hughes SpaldingMay 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 daysPMH: asthma, 3 admissions for asthmaMed: Advair, Albuterol MDIAllergies: 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 Gravity or compression

with bandage Tourniquet

Pneumatic cuff to 250 mm Hg in arm or 50 mm Hg > SBP

Medicine 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 lidocaineIn 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.