Of course I agree wholeheartedly, Ray. And as for equipment, if you're
using this technique regularly, the - fairly simple - equipment is always
to hand. It only takes 15 minutes (of cuff time), 20 minutes overall, and
the block provides similar operating conditions to general anaesthesia. In
other words it's difficult to give a poor block, as you suggest.
On the other hand I frequently see haematoma blocks given with poor levels
of patient comfort, and therefore poor operating conditions for
the "surgeon". I also wouldn't be comfortable with that small dose of
marcain in a haematoma block, given the evidence of systemic toxicity
quoted earlier.
But getting back to this lady, as much as I'm a fan of Bier's block, I've
never given a bilateral one. There's no strong rationale to this view, it's
just that I feel it's rather unfair on the patient, not to mind
the "operator/sedationist" which I am, to go through all of that. When you
factor in that I'd probably leave a 15-minute gap or so between each side
to be sure of avoiding toxicity problems, then we'd be talking about an
hour's work on the patient overall, and I'd rather go for a sedation/GA
type of approach instead.
And as much as I'm a fan of ketamine sedation, at 99 years old (and I'm
talking about the patient here in case you've misread that!) I'd err on
the "discretion is the better part of valour" philosophy and enlist the
help of anaesthetists and surgeons to sort her out; in other words, I'd
admit her. Of course, the four-hour targets are also playing on my mind,
sadly, so I don't like to get caught up in any sort of case for more than,
say, 20 or 30 minutes, lest the rest of the department gets "out of
control".
Adrian
On Sat, 11 Dec 2004 16:02:08 -0000, Ray <[log in to unmask]> wrote:
>Sounds like a good reason to repeat the study then.... Bier's Block versus
>Haematoma Block.
>
>The advantage of the Bier's block is that it is not so dependant on
>technique.
>
>In my own experience and observing practice of others. Haematoma block is
>quicker for the doctor, but not so nice for the patient. The majority of
>doctors don't seem to have "good technique" for a haematoma block.
>
>Ray McGlone
>
>----- Original Message -----
>From: "Paul Ransom" <[log in to unmask]>
>To: <[log in to unmask]>
>Sent: Saturday, December 11, 2004 12:19 PM
>Subject: Re: Bilateral Colles Fractures
>
>>I am sure we have been round the block on this one already.
>> I would be fairly sure that haematoma blocks fare worse in trials thus
>> far mostly because of poor technique. This is partly because of
>> concentrating on the radial component, whereas any impacted fracture
>> will have seriously disrupted the triangular fibrocartilage complex on
>> the ulnar side, and 5 mls judiciously applied here in almost all cases
>> can help towards a pain free block. Sometimes need to wait 10 minutes.
>>
>> I would agree with Adrian a few shots back, in that two broken wrists,
>> even in a stoic elderly lady, cause a lot of pain. Adding some
>> marcaine into the block to give longer lasting effect is kind and I have
>> been doing this or many years without a single adverse effect.
>>
>> Paul Ransom
>>
>> -----Original Message-----
>> From: Accident and Emergency Academic List
>> [mailto:[log in to unmask]] On Behalf Of Doc Holiday
>> Sent: 11 December 2004 11:44
>> To: [log in to unmask]
>> Subject: Re: Bilateral Colles Fractures
>>
>> Best Evidence is to use Bier's Block not Haematoma Block
>> http://www.bestbets.org/cgi-bin/bets.pl?record=00008
>>
>> --> But that's a BET, not a GET (G=Good). The BET (Which seems very well
>> done) is phrased very carefully to say that it's based on the "best
>> evidence available at the present time ". When you consider how rare it
>> is for evidence they found to be BLINDED (ONE study), you wonder whether
>> there is a chance that we have here Bier's-lovers proving their own
>> case.
>>
>> I can tell you that on most places I've worked it would take longer to
>> find the Bier's equipment than to do a haematoma block and have the
>> patient back to a fracturse clinic...
>>
>> I believe we have here another one of MANY situations where the BEST
>> option is to have more than one option...
>>
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