The Bier Block

For fracture reductions in the ED, there are obviously several analgesic options in your armamentarium.  There's the tried and true hematoma block, there's sometimes tricky yet potentially rewarding regional nerve blocks, and then there's time and labor intensive but enormously effective moderate sedation.  But what about intravenous regional anesthesia, AKA the fabled Bier Block?  

Stop the record for a second, did I just say intra-VENOUS regional anesthesia?  You heard me--and surgeons and anesthesiologists have been doing it in the OR for years.  Indications also include distal fractures that require reduction, major lacerations, foreign body removal, abscess drainage--pretty much any procedure on distal extremities that hurts like stink. The procedure is simple: the limb is exsanguinated with pneumatic cuffs, and a local anesthetic is pushed as distally in the limb as possible (via a 20 or 22 gauge catheter--the hand is a great place to go).  The procedure is performed, and the cuffs are slowly removed.  The patient is fully alert but comfortable, and receives no systemic sedation.  

Your list of supples are as below, and should be easily obtained in any shop.

Specifically, you dose your lidocaine at 3 mg/kg, injected as a 0.5% saline bolus.  You achieve this by mixing it with equal parts saline in a 60 cc syringe.  Example: a 70 kg patient would get 210 mg of lidocaine, which would come out to be 21 cc of solution, then mixed with another 21 cc of saline.  Then inflate the cuff and attach the Esmarch sequentially as listed above, or just use two separate cuffs.  Once you're done, make sure to 1.) Wait until the total on-cuff time is 30 minutes and 2.) cycle the cuff off, slowly deflating for 5 seconds, then re-inflating for 1 to 2 miniutes.

How safe is this?  It sounds frighteningly bold but there has actually never been a recorded case of a mortality, at least from a patient that has had lidocaine as the anesthetic.  The only real recognized absolute contraindication is a lidocaine allergy.  Relative contraindications include Raynaud's, Buerger's disease, crush injuries, and sickle cell disease (homozygotes).

The history is quite interesting, dating back to the eponymous August Gustav Bier himself, a surgeon who appeared to be ahead of his time.  Surprisingly, the concept arose from the belief from the time that  sequestering an infection (in this case tuberculosis) into one extremity via congestion from a tourniquet  promoted healing.   While testing this wacky hypothesis in 1908 he somehow also came to the conclusion that injected these exsanguinated limbs via venous cutdown with novocaine (the "new" cocaine at the time), he obtained fantastic analgesia that was rapidly reversible.

 Unfortunately, like several other groundbreaking physicians (Reiter, Wagener, Clara, Seitelberger, etc.) he also happened to be a Nazi.  Why'd you have to go there, dude?

Let's get back from the stone ages here so you can catch Dr. Al Sacchetti performing the procedure.  Note that the patient experiences zero pain during the procedure and is fully alert. 

Depending where you're at, your nurses may not be a big fan of this, as it does require additional staff and arguably may be more complex and time consuming than regular procedural sedation.

Finally, just as it is for any other procedure we write about here, this post is for educational purposes ONLY.  Please do not assume you are a Biermeister Supreme after this and start pushing boluses of lidocaine on people.  Be smart.

jps


Sources:  

Zundert, A. et al.  Centennial of Intravenous Regional Anesthesia. Bier's Block. (1908-2008). Regional Anesthesia and Pain Medicine.  2008 Sept.-Oct; 33(5): 483-9.

Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition.  Chapter 23.