Bier’s Block

This intravenous regional anaesthesia technique is commonly used for the manipulation of Colle’s fractures in the ED.

Indications

  • Manipulation of wrist and forearm fractures
  • Clean and repair of multiple forearm lacerations
  • Foreign body removal from forearm wounds

Contra-indications

Absolute

  • Amide local anaesthetic hypersensitivity
  • Congenital/ Idiopathic Methaemoglobinaemia
  • Severe hypertension (SBP>220mmHg)
  • Compartment Syndrome
  • Uncooperative patient
  • No IV access on affected hand and other limb

Relative

  • Coagulopathy
  • Cardiac conduction abnormalities
  • Vascular disease of affected limb
  • Sickle cell anaemia
  • Epilepsy
  • Local inflammation/ infection
  • Children (<10yrs)
  • Pregnancy
  • Lactation

Preparation

Patient

  • Check Indications and Contraindications
  • Explanation and Reassurance
  • Check Weight (see drugs) and SBP
  • Informed Consent (verbal)
  • Risks of procedure (see complications)
  • Risks and inadequacies of alternative methods including Haematoma Block, Conscious sedation and General anaesthesia
  • Patient competency
  • Patient comprehension
  • Patient decision

Area

  • Monitored cubicle with oxygen and suction

Staff

  • Minimum two doctors (at least one doctor must be experienced in the procedure)
  • Doctor 1 administers the drugs, monitors the patient for side-effects, cuff integrity and cuff tolerance by patient
  • Doctor 2 performs the manipulation or procedure
  • Minimum one nurse
  • For fracture reductions inform radiology staff that a portable post-reduction X-ray will be required immediately after reduction

Equipment

  • Comprehensive non-invasive monitoring (ECG, HR, BP, sats)
  • Double-cuff tourniquet
  • Plaster trolley
  • Padding
  • Plaster of Paris (8-10 layers, pre-sized and cut to fit patient)
  • Crepe bandage
  • Bowl containing luke-warm water
  • ‘Bluey’ beneath arm

Drugs 3

For procedure (drawn up):

  • 0.5% Prilocaine
  • Dose 3mg/kg (0.6ml of 0.5% Prilocaine x patients weight in kg)
    • eg a 70 kg patient gets 210mg (42ml) 0.5% Prilocaine
  • Max dose 400mg (80ml)

For potential complications (readily available in cubicle):

  • Seizures: Midazolam 2.5-5mg IV (0.1mg/kg children)
  • Methaemoglobinaemia: Methylene blue 1% (1mg/kg), High flow O2 by NRM
  • Cardiac arrest: Adrenaline 1:10,000 1mg IV

Procedure

  • Position the patient : On trolley, Supine
  • IV line insertion: Insert small (22G) IV line into dorsum of hand of affected limb (to administer prilocaine) and a second IV line (20G) in other arm (to administer treatment in event of complications)
  • Attach and check cuffs: Attach double-cuff to patient’s affected arm and check function of each cuff
  • Exsanguinate arm: Elevate limb for 60secs and exsanguinate arm using Esmarch’s bandage or by manually squeezing muscle compartments
  • Inflate upper cuff: Re-check patient’s blood pressure and inflate proximal (upper) cuff to 100mmHg above SBP
  • Cease exsanguination: Remove Esmarch’s bandage/ manual compression and then lower arm
  • Palpate: for the brachial pulse to ensure the tourniquet has occluded blood flow
  • Inject Prilocaine: Inject pre-calculated dose of Prilocaine into affected limb as a slow IV bolus
  • Remove IV line: of affected limb
  • Wait for anaesthesia: Do not commence the procedure until adequate analgesia achieved, best checked by palpating fracture site. Usually takes 3-5mins, but can take up to 15mins
  • If patient can not tolerate cuff discomfort: Inflate the distal (lower) cuff (on anaesthetized skin) to 100mmHg above SBP and then deflate upper cuff (proximal cuff)
  • Perform Procedure: Reduce fracture / Suture / Remove foreign bodies, as indicated. Obtain a post-reduction X-ray BEFORE deflation of the cuff as re-manipulation may be necessary
  • Observe patient (for signs of toxicity) and Cuff pressure (not dropping) throughout the procedure
  • Measure blood pressure: every 5mins and ensure cuff pressure remains 100mmHg above SBP
  • Cuff Deflation: the cuff should not be let down until at least 25 minutes have elapsed. Deflate cuff briefly (for 5-10secs) then re-inflate. If no signs of toxicity after 45 seconds then deflate again (for 5-10secs). Repeat this once more prior to being permanently removed.

Complications

  • Prilocaine toxicity: symptoms include dizziness, peri-oral tingling, metallic taste, altered mental status and seizures.
  • Methaemoglobinaemia manifests as signs of hypoxaemia with cyanosis, chest pain, dyspnoea or confusion. Pulse oximetry is unreliable for its detection. Refer to Toxicology Handbook.4
  • Cardiac arrest: follow ALS algorithm and consider Intralipid.

After care

  • Observe minimum of 1 hour post procedure. 15-30 minutely neurovascular obs should be performed during this time.
  • From a procedural point of view, patients are safe for discharge once sensation begins to return to the limb
  • Do not remove IV from normal limb until observation period complete

Disposition

  • Consider ability to cope at home. May need EDU admit with CCT review.
  • Arrange orthopaedic follow up

Documentation

  • Document the details of the procedure

 

References

  1. Miller’s Anaesthesia, 8th Edition
  2. Illustration: www.netterimages.com
  3. Australian Medicines Handbook July 2015
  4. Toxicology Handbook, 3rd Edition

 

Date implemented – 09/2015
Review date – 09/2018
Author – Shelley Kirkbright

 

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