Procedure Talk: the Bier Block

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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

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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
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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, lt2 sec cap refill, moves fingers,
  sensation grossly intact

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Options?

• Sedation and analgesia
• Axillary block
• Hematoma block
• Bier block

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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, lt2 sec cap refill, moves fingers,
  sensation grossly intact

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Sedation and analgesia

• PROs
• great for anxiety and pain relief
• CONs
• NPO status
• Wheezing
• Small mouth

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Axillary block

• PROs
• great for prolonged pain relief
• CONs
• painful procedure
• obese habitus
• apprehensive child

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Hematoma block

• PROs
• great for pain relief
• CONs
• apprehensive child

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Bier block

• NO. IT HAS NOTHING TO DO WITH THIS.

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Bier block

• IV regional anesthesia
• August Bier, 1908
• Modern version, 1970s

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Preparation

• Anxiolysis
• Muscle spasm
• Uncooperative patient
• IV in affected extremity

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Procedure

• Exsanguination
• Gravity or compression with bandage
• Tourniquet
• Pneumatic cuff to 250 mm Hg in arm or 50 mm Hg gt
  SBP
• Medicine
• Lidocaine 1.5-3 mg/kg over a minute
• 0.33 Lidocaine 3 mg/kg
• Procedure after 3-6 minutes

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Post-procedure

• Deflate for a few seconds
• Re-inflate for a minute
• Rinse, lather, and repeat
• Observe for 15 minutes
• Discharge

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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

• 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

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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
• Instead of lidocaine
• In addition to lidocaine

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Bier block Indications

• Closed fractures
• Burn debridement
• Removal of ground-in debris
• Abscess ID
• 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.