/ Tasmanian Department of Health and Human Services
Royal Hobart Hospital
Clinical Guidelines

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RHH Emergency department Intravenous regional anaesthesia: Biers Block / Ed-1-0012
  • Background
  • Objective
  • Contraindications
  • Principles of Management
/
  • Follow-up
  • References
  • Stakeholders
  • Key Words

Background

Intravenous Regional Anaesthesia (Biers Block) is a procedure often undertakenin the emergency department for children (over 10 years old) and adults with single closed forearm and lower leg fractures or lacerations requiring manipulation or repair that can be completed within a 40-60minutes timeframe.It is a technique utilising the injection of rapid onset anaesthesia into a vein distal to the injury to gain muscle relaxation and anaesthesia, while a proximal tourniquet remains in place.It can often avoid the patient undergoing a general anaesthetic and decrease hospital length of stay.

Objective

The aim of this guideline is to promote consistent management of patients requiring Intravenous Regional Anaesthesia (Biers Block) within the Emergency Department (ED).

Contraindications

  • Uncooperative patient
  • Age of patient (less than 10 years )
  • Unstable epilepsy
  • Uncontrolled hypertension
  • Severe liver disease
  • Peripheral vascular disease
  • Lack of availability of resuscitation equipment
  • Procedure lasting greater than 60 mins
  • Allergy to anaesthetic agents
  • Injury at tourniquet site
  • Second or third degree heart block
  • Severe vascular disease
  • Sickle cell disease
  • Open fractures

Principles of Management

Requirements before starting procedure:

  • Available staff including ED registrar or consultant with airway management skills and Biers blocks experience, and a procedure doctor. A procedure nurse withBiers Block experience must be available to monitor both the patient and the Biers Block machine/cuff
  • Obtain patient consent
  • Obtain patient’s weight
  • Ideally the patient will have been fasting for a minimum of 4 hours
  • Resuscitation equipment available: oxygen, suction, BVM,and airway adjuncts
  • Oxygenation and anticonvulsants are the main treatment if accidental cuff deflation occurs, the first signs of local anaesthetic toxicity are indicated by peri-oral tingling/numbness, followed by altered conscious state and seizures. If toxicity occurs an Intralipid infusion is recommended
  • Radiographer must be notified and be available to provide post reduction films prior to cuff release

Technique:

  • Insert two IV cannulas, one small gaugedistal to the injury in the limb (usually medical officer will insert this)undergoing the procedure, and one in the opposite limb for emergency access.
  • Apply several layers of Velband around the upper arm of the affected limb to provide padding and protection under the tourniquet.
  • Record a full set of baseline vital signs and record on the Procedural Sedation Form.
  • Apply tourniquet cuff to the upper arm of the affected limb—preferably with the connector tubing facing proximally so as not to interfere with plaster application.
  • Elevate the injured limb for several minutes to allow venous drainage and improve the effectiveness of the Local block and decrease discomfort.
  • Inflate the proximal cuff before lowering the limb. Check cuffs for leakage: Inflate proximalcuff to the desired pressure (usually 100mmHg greater than the patient’s systolic blood pressure but less than 300mmHg).Confirm absence of pulse.
  • Inject 0.5-0.7 ml/kg of 0.5% Prilocaine (generally 40mls for a 70kg adult), this will anaesthetise the distal area allowing for the distal cuff to be inflated to the pressure determined above.The proximal cuff can then be deflated.
  • Document time of cuff inflation. Set time on the Biers Block machine. The cuff should be left inflated for a minimum of 20mins (to allow for good tissue binding of Prilocaine and decrease systemic toxicity), but left on no longer than one hour (to prevent limb ischaemia).
  • Remove the IV cannula on the injured side and apply pressure to the site until bleeding ceased.Do not cover with a dressing as limb will be plastered.
  • Assess completeness of the block at 10mins.If anaesthesia is satisfactory then reduce and plaster the fracture.
  • Obtain lateral and AP films of limb.If satisfactory, then release the cuff (not before 20mins).If unsuccessful then attempt further reduction and release the cuff—more than two attempts are unlikely to improve the fracture so ongoing limb ischaemia is unwarranted.
  • If the reduction is successful then observe the patient for 60 mins prior to discharge.

Follow-up

The following needs to be completed when the patient is ready for discharge:

  • Fit sling and elevate limb.
  • Ensure adequate analgesia to go home with.
  • Discuss the signs and symptoms of neurovascular compromise.
  • Follow up in fracture clinic in 7 days or by private Orthopaedic Surgeon.
  • Give patient plaster care instruction leaflet and instructions to return to GP if signs and symptoms of limb ischaemia occur.
  • Emergency Multidisciplinary Team (EMAT) referral if patient more than 65 years old

References

  1. Guay, J., 2009, Adverse events associated with intravenous regional anaesthesia (Bier block): a systematic review of complications,Journal of Clinical Anaesthesia, 21, pp 585-594.
  2. Sprot, H., Metcalfe, A., Odutola, A., Palan, J., White, S., 2012, Emergency Medical Journal, March.

Stakeholders

Emergency Department Royal Hobart Hospital Consultants

Emergency Department Director

Emergency Department NUM

Emergency Department Royal Hobart Hospital CNC

Emergency Department Royal Hobart Hospital CNEs

Key Words

1. Intravenous regional anaesthesia

2.Rapid onset analgesia

3.Cannula

Custodian:Emergency Department CNC
Authorised by:Director Emergency Medicine / Effective Date:September2013
Review Date:September 2017

Document File Name: Biers Block GuidelinePage 1 of 4