I think Paul has made the key point in the method that blocking the ulna
aspect of the wrist (infiltrating just distal to the ulna styloid including
the radio-carpal joint) as well as the fracture site and WAITING 15 minutes
or so is key the success. I use up to 2 mg/kg of 1 % lignocaine for its
speed of action - using bupivacaine takes significantly longer. Despite this
once the fracture has been reduced and held in a cast, analgesia is usually
less of an issue.
It is important that the wrist x-rays are readily available for inspection
so that the precise position of the fracture site can be determined in the
swollen wrist. I use a 23 G needle followed by a 21 G needle and infiltrate
slowly. In elderly patients impacted fractures are rarely problematic as the
bones are usually osteoporotic.
Despite intuition, we have NOT had any problems with infection and there is
nothing in the literature to support an excess of bony infection with this
method of block. Lack of muscular relaxation has not compromised
satisfactory reduction if satisfactory local anaesthesia has been achieved,
and patients can be instructed to relax if need be. I do happen to make note
of any verbal/non verbal clues from the patient re efficacy of the block
throughout the procedure.
The major issue I have with Bier's block is freeing up the necessary
resources (resus room type environment) for this procedure to be safely
performed. I have also been struck by how painful the cuff is for many
patients when a single cuff technique is used (as has been encouraged for
use in the ED to reduce the risk of the wrong cuff being deflated during the
procedure).
I would be interested to know from Jason precisely what type
instruction/method etc the doctors who performed haematoma blocks received
in his study.
John Black
Oxford
-----Original Message-----
From: Paul Ransom [mailto:[log in to unmask]]
Sent: 30 September 2002 09:21
To: [log in to unmask]
Subject: Re: Bier Blocks
Given up on Bier blocks by now, thanks to time constraints. Haematoma
blocks so much faster. My experience is that failure rate in haematoma
blocks as opposed to Biers concerns inadequate dosage of anaesthetic, and
most likely omitting to inject over the ulnar side of the wrist aswell, as
there will usually be damage here too. So, two injection sites usually,
but I can (nearly) always get excellent anaesthesia with this site. I use
marcaine, on the basis that this is what I would want for myself.
Sometimes,when the department is busy, or a long wait in x-ray, I will put
in the block on first sight, and give it a tweak, and so just get back an
x-ray in POP, if it is clinically obvious this is a Colles. Patients
usually happy to be out of the department in under an hour, if lucky.
As for the haematoma, not always possible to get into this, if there is
more of an impaction. Can't say that I've noticed any decrease in analgesia
since not routinely aspirating x mls of blood back.
Paul Ransom
A&E Brighton
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