1. 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

2. 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

3. 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

4. Options? Sedation and analgesia Axillary block Hematoma block Bier block

5. 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

6. Sedation and analgesia PROs great for anxiety and pain relief CONs NPO status Wheezing Small mouth

7. Axillary block PROs great for prolonged pain relief CONs painful procedure obese habitus apprehensive child

8. Hematoma block PROs great for pain relief CONs apprehensive child

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

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

11. Preparation Anxiolysis Muscle spasm Uncooperative patient IV in affected extremity

12. 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

13. Post-procedure Deflate for a few seconds Re-inflate for a minute Rinse, lather, and repeat Observe for 15 minutes Discharge

14. Bier block: PROs No need for NPO status Pt is awake during procedure. Shorter post-procedural observation time

15. Bier block: CONs Lose pulse Possible superficial nerve damage Unable to splint or cast with tourniquet inflated

16. 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

17. Bier block: Contraindications Shock Multiple trauma Hypersensitivity to lidocaine Seizure disorder Sickle cell disease

18. Bier Block: Controversies Dose of lidocaine Volume of lidocaine infusion Other meds Instead of lidocaine In addition to lidocaine

19. Bier block: Indications Closed fractures Burn debridement Removal of ground-in debris Abscess I&D Laceration repair Foreign body removal Limited surgical procedures

20. 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.