Procedure Talk the Bier Block John Cheng MD

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 Tshirt 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 Tshirt 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 l ¢ great for anxiety and pain relief CONs l l l NPO status Wheezing Small mouth

Axillary block ¢ PROs l ¢ great for prolonged pain relief CONs l l l painful procedure obese habitus apprehensive child

Hematoma block ¢ PROs l ¢ great for pain relief CONs l apprehensive child

Bier block ¢ NO. IT HAS NOTHING TO DO WITH THIS.

Bier block ¢ ¢ ¢ IV regional anesthesia August Bier, 1908 Modern version, 1970 s

Preparation ¢ Anxiolysis l l ¢ Muscle spasm Uncooperative patient IV in affected extremity

Procedure ¢ Exsanguination l ¢ Tourniquet l ¢ Pneumatic cuff to 250 mm Hg in arm or 50 mm Hg > SBP Medicine l l ¢ 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: l l 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 l In addition to lidocaine l

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. ¢