See also    

Acute pain management
Local anaesthetic poisoning
Communicating procedures to families

Key points

1. Bier block can provide safe and effective anaesthesia in select children with forearm injuries requiring manipulation or repair in the emergency department
2. Tourniquet must not be deflated before 20 minutes to minimise risk of local anaesthetic poisoning

Background

• A Bier block is a form of regional anaesthesia, where local anaesthetic is given intravenously with a tourniquet applied to stop it from spreading systemically
• Limb neurovascular observations must be documented prior to performing regional anaesthesia
• Clinicians would benefit from supervision if they do not have prior experience with the procedure, and must be able to provide resuscitation if local anaesthetic poisoning occurs

Indications

• Cooperative child with forearm fracture requiring manipulation or laceration needing repair

Contraindications

• Local anaesthetic allergy/anaphylaxis
• Open fracture
• Severe hypertension (reconsider if systolic blood pressure >175 mmHg)
• Severe crush injury or compromised circulation
• Sickle cell disease

Potential Complications

• Cuff discomfort (common)
• Allergy/anaphylaxis to lidocaine (lignocaine)
• Systemic lidocaine toxicity (rare): agitation, headache or dizziness, tinnitus, blurred vision and tongue numbness or metallic taste can be early signs. Severe toxicity may cause seizures, methaemoglobinaemia, cardiovascular and respiratory compromise
  • In case of suspected lidocaine (lignocaine) toxicity: stop injection, confirm tourniquet inflation and provide resuscitation

Equipment

• Pneumatic tourniquet
• Soft wrap to place under tourniquet for comfort
• Two IV cannulas and associated set-up
• Lidocaine (lignocaine) 1%
• Equipment (eg plaster or suture material) needed once block is complete

Analgesia, Anaesthesia, Sedation

• Ensure adequate analgesia of underlying injury (see acute pain management)
• Topical anaesthetic cream for insertion of IV cannulas
• Local anaesthetic for the block:
• Dilute lidocaine (lignocaine) 1% with an equal quantity of normal saline to make a 0.5% solution
• Lidocaine (lignocaine) dose: 3 mg/kg (0.6 mL/kg of 0.5%; max 200 mg or 40 mL) 

Procedure – step by step

• Obtain blood pressure, apply cardiac leads and oxygen saturation
• Provide clinical monitoring for signs and symptoms of systemic lidocaine (lignocaine) toxicity
• Insert an IV cannula into a distal vein of the affected arm. The insertion of a second IV cannula in the unaffected arm is recommended
• Apply pneumatic tourniquet to the affected arm (a soft wrap under the cuff may improve comfort)
  • If available use the recommended tourniquet pressure (RTP) feature
  • When not using the RTP feature, set the tourniquet pressure to 75 mmHg above the patient’s systolic blood pressure (max tourniquet pressure of 250 mmHg)
• Before inflating cuff, perform limb exsanguination by elevating the affected arm for at least 1 minute
• With the arm still elevated, inflate the tourniquet cuff to the RTP or previously established tourniquet pressure
• Start a timer
• Squeeze the cuff to observe pressure oscillations
• Confirm absence of radial pulse
• Inject 0.5% lidocaine (lignocaine) into IV on the affected side
• Remove IV cannula from affected arm and apply prolonged direct pressure to avoid bleeding
• Commence procedure, for which the block is required, only after adequate anaesthesia has been obtained (usually 5-10 minutes after infiltration)
• Do not deflate the tourniquet before 20 minutes or later than 45 minutes after lidocaine infusion  

Post-Procedure Care and Discharge instructions

Check limb circulation and ensure no signs of local anaesthetic poisoning after tourniquet deflation

Alternatives if the block is not successful

Consider transfer when

• Staff unable to safely perform the procedure
• Uncontrollable pain
• Fracture requiring surgical treatment not able to be performed at presenting hospital
• Signs of local anaesthetic poisoning – will need discussion with retrieval team

Consider discharge when

Follow-up plan for injury in place and adequate ongoing pain relief provided 

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services. 

Parent information

Last updated November 2020