Emergency Medicine

488 Practical Procedures

BIER’S INTRAVENOUS REGIONAL BLOCK

INDICATIONS

1 Anaesthesia for the reduction of distal forearm fractures.

CONTRAINDICATIONS

1 Inabilit y to site i.v. cannula in injured-side hand (cannot proceed).

2 Peripheral vascular disease, Raynaud’s phenomenon or local sepsis.

3 Hypertension with systolic blood pressure >200 mmHg, uncooperative

patient (including children who will not tolerate cuf f pressure).

4 Local anaesthetic sensitivity (rare), homozygous sickle cell disease (even

rarer).

5 Relative: patients who have sustained a crush injury of the limb, as poten-

tia lly v iable tissue will be subjected to a f urt her period of hy poxia.

TECHNIQUE

1 Two doctors are required, one with anaesthetic experience and previous

training in the procedure to perform the block, and the other to perform the

manipulation.

(i) At least one nurse attends to the patient, checks the blood

pressure and assists the doctors.

2 Explain the technique to the patient, who should sign a written consent

form.

3 ECG and blood pressure monitoring must be available in an area with full

resuscitation facilities and a tipping trolley. Ideally the patient should be

starved for 4 h before the procedure.

4 Use a specifically designed and properly maintained Bier’s block cuff, and

check first for leaks or malfunction. Apply the cuff to the upper arm over

cotton-wool padding.

5 Insert a small i.v. cannula into the dorsum of the hand on the affected side

and a second cannula into the other hand or wrist.

6 Elevate the affected arm for 2–3 min to empty the veins in preference to

using an Esmarch bandage, which is generally too painful.

7 Inf late the cuff to 100 mmHg above systolic blood pressure, keeping the arm

elevated, but to no more than 300 mmHg. The radial pulse should no longer

be palpable and the veins should remain empty.

8 Lower the arm and slowly inject 0.5% prilocaine 2.5 mg/kg (0.5 mL/kg) and

make a note of the time of injection.