Bier Block

[Groove]

Am I the only one that does Bier blocks? I have yet to meet a single EM doc in my career thus far who has any experience doing them. I'm hard pressed to even find any of our ortho residents who have done more than 1 or 2 and that's usually at our trauma center with an ancient, crusty attending. Which...now that I think about it was exactly the types of docs I rotated with during my ortho rotation in residency. I think I learned them there and continued to do them throughout residency but now that I think about it, I'm not sure if other residents were doing them. I honestly can't really remember when I started doing them but it was definitely in residency which leads me to believe someone showed me at some point. I'm starting to think it was just an aberration in teaching. Either that or I'm just getting old.

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[Groove]

Am I the only one that does Bier blocks? I have yet to meet a single EM doc in my career thus far who has any experience doing them. I'm hard pressed to even find any of our ortho residents who have done more than 1 or 2 and that's usually at our trauma center with an ancient, crusty attending. Which...now that I think about it was exactly the types of docs I rotated with during my ortho rotation in residency. I think I learned them there and continued to do them throughout residency but now that I think about it, I'm not sure if other residents were doing them. I honestly can't really remember when I started doing them but it was definitely in residency which leads me to believe someone showed me at some point. I'm starting to think it was just an aberration in teaching. Either that or I'm just getting old.

And I'm not arguing they are superior in any way or I'm a fancy pants for using them. Hell, they probably take just as long to set up for compared to sedation but sometimes are easier if I don't want to sedate/contraindication, etc.. I'd say 95% of the time I'm using them for bad colles reductions. I just always assumed they were incorporated more frequently in EM training but I think my experience was atypical.

 

[JacobMcCandles]

I don't and nobody I know does them.

 

[gruemd]

I'm gonna be honest, and maybe this makes me a dumb doctor, I had to google what that even is. Haven't done it or seen it done. Do you prefer it over a hematoma block?

 

[oldtown]

Am I the only one that does Bier blocks? I have yet to meet a single EM doc in my career thus far who has any experience doing them. I'm hard pressed to even find any of our ortho residents who have done more than 1 or 2 and that's usually at our trauma center with an ancient, crusty attending. Which...now that I think about it was exactly the types of docs I rotated with during my ortho rotation in residency. I think I learned them there and continued to do them throughout residency but now that I think about it, I'm not sure if other residents were doing them. I honestly can't really remember when I started doing them but it was definitely in residency which leads me to believe someone showed me at some point. I'm starting to think it was just an aberration in teaching. Either that or I'm just getting old.

Had to look up what exactly it is. So, to answer your question, yes, you are the only one doing them, at least as far as I’m concerned.

 

[Groove]

I'm gonna be honest, and maybe this makes me a dumb doctor, I had to google what that even is. Haven't done it or seen it done. Do you prefer it over a hematoma block?

LOL, I'll have to add it to my growing list of moribund skills.

Yeah, it has a lot better analgesia compared to hematoma. You can really crank on the wrist with the patient reasonably comfortable.

 

[Dr Mantis Toboggan]

I'm gonna be honest, and maybe this makes me a dumb doctor, I had to google what that even is. Haven't done it or seen it done. Do you prefer it over a hematoma block?

Always thought of it as an OR thing.

 

[Angry Birds]

Stop making up words

 

[CajunMedic]

I haven’t seen one since Paramedic school. We didn’t even train on them in residency. I don’t even think we have the equipment to do one if I wanted to

 

[Fox800]

Never trained on it during residency.

 

[Rendar5]

I’m familiar with them but not outside an OR setting

 

[Arch Guillotti]

bier blocks are ridiculous and outdated just an accident waiting to happen.

 

[Tiger26]

Never met someone who does them or met anyone who's met anyone doing them in the ED

 

[Groove]

Sigh

 

[bky3c]

I had one co-resident who was really big on them for some reason... which was funny because he consistently mispronounced "Bier."

 

[Apollyon]

I had one co-resident who was really big on them for some reason... which was funny because he consistently mispronounced "Bier."

As what? I thought it was pronounced as "beer"?

 

[Groove]

As what? I thought it was pronounced as "beer"?

Same. I can’t imagine how you’d say it. “Bye Air”?

 

[thegenius]

I’ve done it once. Why did that guy above say it’s just an accident waiting to happen? I actually think when I did it…it was Ok if I remember

 

[EMhawkeye]

Used to see them all the time in the OR on ortho but never the ED

 

[Apollyon]

Same. I can’t imagine how you’d say it. “Bye Air”?

Yeah, in fact, "four" in German is "vier", which also rhymes with "beer".

 

[IMGASMD]

Just lurking. From anesthesia.

I’ve never done one in residency, I graduated -6 years ago. But I’ve done 1 in practice with a partner, for an Ortho hand doctor, who is younger than me…. She trained at some big name place, and she says someone in her training had taught them it can help with pain modulation. So she would request a heavy MAC/Gen with Bier block, talk about a ****ing disaster waiting to happen.

Shooting large amounts of local anesthetics into the vasculature just does not appeal to me…. I wonder why. Just think during the olden days of lidocaine for acls…. 100mg is the dose…. Injection of up to 300mg to numb just sounds no bueno to me.

 

[BoardingDoc]

I’ve done it once. Why did that guy above say it’s just an accident waiting to happen? I actually think when I did it…it was Ok if I remember

Because you're a cuff malfunction away from potentially giving the patient LAST. Or they could develop LAST anyway as soon as you take the cuff down depending on their weight and how much lido you use. The risk : benefit ratio is horribly skewed towards risk in basically every conceivable scenario.

 

[RustedFox]

Because you're a cuff malfunction away from potentially giving the patient LAST. Or they could develop LAST anyway as soon as you take the cuff down depending on their weight and how much lido you use. The risk : benefit ratio is horribly skewed towards risk in basically every conceivable scenario.

LAST?

 

[IMGASMD]

LAST?

Local anesthetic systematic toxicity.

Something that we keep in mind when we do any regional techniques.

https://www.nysora.com/local-anesthetic-systemic-toxicity-last/

 

[TooMuchResearch]

And I'm not arguing they are superior in any way or I'm a fancy pants for using them. Hell, they probably take just as long to set up for compared to sedation but sometimes are easier if I don't want to sedate/contraindication, etc.. I'd say 95% of the time I'm using them for bad colles reductions. I just always assumed they were incorporated more frequently in EM training but I think my experience was atypical.

In this thread, Groove makes a post asking if anyone else does Bier blocks and then Groove is the first one to quote and respond to the post, which probably answers the question

But no, I always thought they were an OR thing and we didn't do them during residency.

 

[TooMuchResearch]

bier blocks are ridiculous and outdated just an accident waiting to happen.

Let's just listen to this guy who probably has more regional anesthesia experience than the entire EM forum and call it good.

 

[southerndoc]

Have a feeling I'm not even credentialed for them. Some places specifically mention them for privileges.

 

[thegenius]

but why not give a non-toxic dose of lidocaine during a bier block? This entire thread is confusing.

 

[TooMuchResearch]

but why not give a non-toxic dose of lidocaine during a bier block? This entire thread is confusing.

View attachment 382362

I think the problem here is that you're giving the local anesthesic via intravascular route so it would take a lot less for you to run into trouble. I've never used lidocaine as an anti-arrhythmic but the internet is telling me that 3 mg/kg is the max cumulative lidocaine dosing after multiple slow boluses.

I think it would be much safer for the patient to just learn some new fangled ultrasound guided regional anesthesia techniques, but every time I think "hey maybe I'll do a femoral nerve or fascia iliaca block for that hip," it takes 40 minutes to find all the supplies and get the procedure done. Ain't nobody got time for that unless they're setting up for me and have everything open and ready before I'm in the room. Good luck with that one.

 

[bky3c]

As what? I thought it was pronounced as "beer"?

Yeah, "beer" is correct (like "pier" or "tier," or apparently... German). He was saying "buyer." Not that I've never mispronounced anything, but if you're going to be the cheerleader for something, you might as well say it right.

 

[Jabbed]

@Groove Are you getting the pneumatic cuff from OR? That doesn’t seem like something that you’d find in ED supply.

 

[Groove]

@Groove Are you getting the pneumatic cuff from OR? That doesn’t seem like something that you’d find in ED supply.

Yeah, if you have ortho (and even general surgery) in your hospital, chances are they have a pneumatic cuff in the OR. Usually a Stryker or Zimmer. They are usually preset at 250 or 300 mmHg and have two circuits. You just connect a double bladder (or even one wide single bladder) cuff, inflate, put 20-30cc lidocaine 0.5% in the arm (usually PIV in the hand), take out the IV, let percolate for about 5-10 minutes and do your reduction. They also work great for messy lacs where you can't inject enough local. Leave the pump up for 20 mins and set a stopwatch because it gets very uncomfortable for pt around 20 min marker. Deflate. Done. Zero complications in 15 years of doing them.

I also use them for repairing bleeding AVF, etc.. They are easy to use machines. The Zimmer can be slightly confusing because you have to tap and slide to engage deflation.

 

[Groove]

Because you're a cuff malfunction away from potentially giving the patient LAST. Or they could develop LAST anyway as soon as you take the cuff down depending on their weight and how much lido you use. The risk : benefit ratio is horribly skewed towards risk in basically every conceivable scenario.

Have you used the pneumatic OR tourniquets? They are dual redundancy channel. It's 2 separate circuits. If the machine gets unplugged, they also have a backup battery. That's like deciding not to use a glidescope because you're afraid the screen will go out. These things are bomb proof to provide surgery and ortho bloodless fields in the OR. I've never even remotely seen one of those things malfunction.

 

[BoardingDoc]

Have you used the pneumatic OR tourniquets? They are dual redundancy channel. It's 2 separate circuits. If the machine gets unplugged, they also have a backup battery. That's like deciding not to use a glidescope because you're afraid the screen will go out. These things are bomb proof to provide surgery and ortho bloodless fields in the OR. I've never even remotely seen one of those things malfunction.

If you note my original comment, I pointed out that this can also happen after you deliberately deflate the cuff at the end of the procedure.

Regardless, you do you man. I'm not saying this isn't a valid technique. I'm saying that I'm a lot more comfortable with the risk involved in a simple hematoma block, and if that isn't cutting it (which in my n=1 is adequate 98% of the time) I'd personally much rather just do a supracondylar block +/- a median nerve block.

Any potential complication where you're thinking of reaching for intralipid to correct the problem is not a situation that I have any desire to be in / defend later.

 

[Groove]

If you note my original comment, I pointed out that this can also happen after you deliberately deflate the cuff at the end of the procedure.

Regardless, you do you man. I'm not saying this isn't a valid technique. I'm saying that I'm a lot more comfortable with the risk involved in a simple hematoma block, and if that isn't cutting it (which in my n=1 is adequate 98% of the time) I'd personally much rather just do a supracondylar block +/- a median nerve block.

Any potential complication where you're thinking of reaching for intralipid to correct the problem is not a situation that I have any desire to be in / defend later.

LAST has an incidence of 0.03% of peripheral blocks. 0.27 episodes per 1000 blocks. I'm usually giving 100-150mg lidocaine tops. Nobody had any problem slamming that during an old world code or close to that dose with one of these new fangled non opioid renal colic/chronic pain protocols. (Plenty of them have bolus followed by infusions)

You're much more likely to suffer a complication during moderate sedation versus a simple bier block. It's really a lot safer than people think but I totally get the hesitancy on here. Hell, I'd be hesitant too if I hadn't done so many but It's not like I'm giving 500-1000mg of lidocaine.

 

[Groove]

And I just wanna say...

Long Live the

block!

 

[Groove]

August Bier - Wikipedia

en.wikipedia.org

 

[Mount Asclepius]

I don’t use largely as a byproduct of it not being a part of my training. Sure, can always develop new skills, but what I do alternatively also works fairly well. A lot of ways to skin a cat. The risks of a bier block is probably over blown for those that were trained on it and especially lower if done correctly, but likely higher for those that do otherwise. I’m much more facile with sedation and other nerve blocks. No reason we all can’t accomplish same goal in slightly different fashion and all have beer together at the end.

 

[coffeebythelake]

bier blocks are ridiculous and outdated just an accident waiting to happen.

We have some young ortho hand guys that like to so them. They are safe but have to be very vigilant. I agree many potential steps for error. And most patients want to be sedated because tourniquet pain is real.

 

[TooMuchResearch]

We have some young ortho hand guys that like to so them. They are safe but have to be very vigilant. I agree many potential steps for error. And most patients want to be sedated because tourniquet pain is real.

Ugh if you give sedation that seems to invalidate a primary reason for doing the block anyway.

 

[GonnaBeADoc2222]

Just give propofol and call it a day

 

[emergentmd]

I try to avoid procedures at all costs not seek them out.

But in all seriousness. I trained at a county hospital 25 yrs ago where DPLs was standard of care where anything goes without much supervision and I never saw one.

 

[The Knife & Gun Club]

For distal radius or ulnar reduction I have switched from hematoma blocks to the periosteal block which is remarkably effective at providing analgesia to the bones of the forearm.

Basically you go several cm proximal to the fracture site enter medically and laterally on the forearm and create a ring of lidocaine around the radius/ulna.

This works very well especially for kids who don’t reliably form blockable hematomas or fractures more than a few hours old where the hematoma is clotted. Most patients tell me the reduction is completely painless or only minimally painful - and that’s with just the usual 4mg push of morphine on arrival. I don’t do any additional pain meds or anxiolytics pre-reduction.

It’s such a reliable block it’s actually used for open ORIFs in Europe.

Bonus points it can be done with US to visualize the lido hydro-dissecting around the periosteum to be sure you’re getting a good ring of local anesthetic in the correct plane. It can be done blind too though.

The paper describing the technique:

Periosteal nerve blocks for distal radius and ulna fracture manipulation—the technique and early results

We present a pilot series of patients with distal forearm fractures manipulated following a proximal periosteal nerve block with local anaesthesia.This is a novel technique which can be utilised in adults and children and is described herein.With a median ...

www.ncbi.nlm.nih.gov

 

[Tenk]

I’ve only seen them used by hand in the OR.

 

[GassYous]

I do it the same way as groove, have done several hundred. We give 5 cc of lido 2% all the time on induction, it's basically the same thing as 20 cc of lido 0.5%. I give 20 cc for forearm stuff, 30-40 cc if we are going past the elbow (less effective). Seems to work better if you have someone holding manual pressure around their forearm to let the local soak in where you are working. Usually can get by with 2 of versed, 50-100 of fentanyl and a small background of prop for decent surgical conditions. I've let the tourniquet down after 15 minutes without problems.

 

[Groove]

I actually did another one today. It wasn’t terribly angulated and I was tempted to just splint and discharge but trudged through. Smooth as usual. Pt rated pain 2/10 during reduction and I was torquing it pretty hard. Excellent reduction. I can’t get better reductions with anything other than mod sedation and it’s about equal. I like to feel that I’m giving them the absolute best chance to escape ORIF.

 

[tkim]

Saw one during med school rotation at USC-LAC in the ER 'cast room'. Saw another one during my ortho/hand rotation in residency in the OR. Two, in 18 years.