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Biers block

  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also

    Acute pain management 
    Communicating Procedures to families

    Key Points

    1. Biers block can provide safe and effective anaesthesia in select children with forearm injuries requiring manipulation or repair in the emergency department.
    2. Biers block should be performed by experienced practitioners.


    Doctors should discuss previous experience and training in this procedure with a senior doctor before proceeding, and should be fully familiar with the equipment used.


    Cooperative children with forearm fractures requiring manipulation or lacerations needing repair.


    • 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

    The most common side effect of Biers Block is cuff discomfort.

    Allergy/anaphylaxis to lignocaine

    Systemic lignocaine toxicity is rare.

    • Symptoms to watch for are: headache or dizziness, tinnitus, blurred vision and tongue numbness or metallic taste.
    • In case of suspected lignocaine toxicity: stop injection, confirm tourniquet inflation and support ABC’s


    • At least two staff members are required to perform the procedure and monitor the patient.
    • A pneumatic tourniquet
    • IV cannulation equipment
    • A soft roll wrap
    • Equipment for the procedure to manage the underlying injury

    Analgesia, Anesthesia, Sedation

    Ensure adequate analgesia of underlying injury (see Acute pain management).

    Local anaesthetic for the block:

    • Dilute lignocaine 1% with an equal quantity of normal saline to make a 0.5% solution
    • Lignocaine dose: 3 mg/kg (0.6 mL/kg 0.5% solution; max volume 40 mL).

    Procedure – step by step

    1. Obtain the patient’s baseline blood pressure. Continuous clinical monitoring for signs and symptoms of systemic lignocaine toxicity is advised.
    2. Insert an IV cannula into a distal vein of the affected arm. The insertion of an IV cannula in the unaffected arm is discretionary.
    3. Apply a pneumatic tourniquet to the affected arm. A soft roll wrap under the cuff may improve comfort.
      • If using a pneumatic tourniquet machine with a recommended tourniquet pressure (RTP) feature, it is advisable to use this 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)
    4. Before inflating cuff, perform limb exsanguination by elevating the affected arm for 1 minute.
    5. With the arm still elevated, inflate the tourniquet cuff to the RTP or previously established tourniquet pressure.
    6. Squeeze the cuff to observe pressure oscillations and confirm absence of radial pulse.
    7. Inject diluted lignocaine (see above) 3 mg/kg (0.6 mL/kg; max volume 40 mL).
    8. Remove IV cannula and apply prolonged direct pressure.
    9. Commence procedure, for which the block is required, only after adequate anaesthesia has been obtained (usually 5-10 minutes).
    10. Do not deflate the tourniquet before 20 minutes or later than 45 minutes after lignocaine infusion.

    Post-Procedure Care and Discharge instructions

    There are no specific post block care requirements once the cuff is released.

    Alternatives if the block is not successful

    In block failure or for children with severe distress, agitation or difficult positioning, additional sedation (see Acute pain management) or general anaesthesia may be required.

    Consider transfer when

    1. Staff unable to safely perform the procedure
    2. Uncontrollable pain
    3. Fracture requiring surgical treatment not able to be performed at presenting hospital
    4. Signs of local anaesthetic toxicity – will need discussion with retrieval team

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.  

    Last updated November 2017