Tasty Morsels of EM 119 – #FRCEM Bier’s Blocks

6 Aug

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here.

(Featured image: via MrArifnajafov on Wikimedia Commons, CC license)

Somehow in the 7 or 8 EDs I’ve worked in I’ve never been in a place that does Bier’s blocks apart from that time i injected 10 litres of lignocaine intravenously by mistake but maybe that doesn’t count…

Anyhow, purely for my own knowledge expansion

RCEM has a guideline on it

When should we not do them?

  • Allergy to local anaesthetic
  • Children – consider whether appropriate on individual basis
  • Epilepsy
  • Hypertension >200mm Hg
  • Infection in the limb
  • Lymphoedema
  • Methaemoglobinaemia
  • Morbid obesity (as the cuff is unreliable on obese arms)
  • Peripheral vascular disease
  • Procedures needed in both arms
  • Raynaud’s phenomenon
  • Scleroderma
  • Severe hypertension
  • Sickle cell disease or trait
  • Uncooperative or confused patient

What drug should we use?

  • 0.5% or 1% prilocaine is recommended in the RCEM document
  • 3mg/kg of prilocaine is max dose (same as lignocaine)
  • max 40mls volume
  • if prilocaine unavailable then can use lignocaine but advice is to dilute it to 0.5% lignocaine

How do we do it?

  • in resus
  • full monitoring (though no CO2)
  • two IV access, one on the ‘normal’ side and one in the ‘broken’ side
  • place the special fancy double cuff tourniquet on the upper arm (not forearm) and elevate to exsanguinate for 3 mins
  • inject your drug
  • check it works
  • cuff must stay up minimum 20 mins, max 45 mins

What could go wrong?


2 Replies to “Tasty Morsels of EM 119 – #FRCEM Bier’s Blocks

    • In terms of what could go wrong I suppose they’re largely theoretical – As mentioned in the post i’ve never actually done a biers!!

      1) either local anaesthetic toxicity form inadvertent systemic spread from tourniquet failure.
      2) methb can happen with prilocaine and one i’ve personally seen/been responsible for with bilateral chest drain insertions in an ICU patient with prilocaine. Though that one was probably an accidental overdosing.

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