procedure talk: the bier block john cheng, md pem fellows conference emory university school of...
TRANSCRIPT
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Procedure Talk: the Bier Block
John Cheng, MDPEM Fellows ConferenceEmory University School of MedicineCHOA at Egleston and Hughes SpaldingMay 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 daysPMH: asthma, 3 admissions for asthmaMed: Advair, Albuterol MDIAllergies: 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, <2 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, <2 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 > 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 lidocaineIn 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.