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Howard
I'm rather dazzled by your message - the whole thing appeared in bright pink, large type with underlining. Very creative.
The saline pump-up is just to get a good vein. The idea is then to let the cuff off, raise the arm, then start the Biers procedure from scratch. I'm not sure the veins could take 100mL if you didn't let the saline go !!
Rob Cocks
-----Original Message-----
From: [log in to unmask] [mailto:[log in to unmask]]
Sent: Friday, February 25, 2000 6:57 PM
To: [log in to unmask]
Subject: RE: Bier's Block
Comment inserted below......
-----Original Message-----
From: Robert Anthony COCKS [SMTP:[log in to unmask]]
Sent: 25 February 2000 05:19
To: [log in to unmask]
Cc: 'acad-ae-med'
Subject: RE: Bier's Block
<< File: ATT00000.htm >> John
I'm puzzled by your mention of a high failure rate. I haven't personally
done any Biers since I've been in HK, but when I routinely used the
technique during winter "Colles season" in the UK, I didn't encounter any
which failed to work out of well over 100 done. There were some where I
failed to find a vein to set up the block in the first place, but using
30-50ml of 1% Prilocaine was always reliable once in. Perhaps I was using a
lot.......?
One useful tip for finding veins for Biers (can't remember the origin now,
but I think one of our A&E colleagues wrote it up in the old BJAEM) is to
cannulate a thready vein on the back of the hand with a tiny butterfly.
Inflate the cuff, then inject 50ml of Saline into the venous system. It
pumps up the bigger veins nicely so they can be cannulated more easily.
Here's a question: if pumping up the veins with saline is OK, why do some people make such a fuss of exsanguinating the arm first, even to the extent of getting the 'big black sausage' from theatre? My own view is that exsanguination is probably a concept hung over from orthopaedic days to produce a bloodless field, not to obtain an effective block. Exsanguination has the disadvantage of reducing the hydrostatic pressure in the veins (now only HALF full of neat prilocaine), and there are no clotting proteins in the veins to stem the flow once you take the cannula out again. I'm not sure that an additional 50ml of saline is such a cool idea either.
My 'failure rate' for Biers block anaesthesia is probably only a few percent, and I find a quick haematoma block on top of the Biers block (if necessary) reduces that almost to nil. Another trick is to put a rubber tourniquet half way up the forearm for the first five minutes to increase the prilocaine concentration around the wrist. I am nervous of the analgesia + midazolam trick: quick & easy no doubt but risky in terms of the patients haemodynamic response to the pain, which they DO feel even if they can't remember it, and if they are flat enough to let you manipulate their wrist, they are flat enough to obstruct their airway without you noticing. For a semi-elective procedure (unlike, say, a dislocated shoulder) I don't think it is acceptable. Besides, a slow careful reduction of a shoulder appears to be considerably less painful than manipulating a broken wrist, therefore an effective dose of morphine (10-20mg) and a smidge of midazolam (1-2mg) is acceptable.
Does anyone audit their Biers block effectiveness and/or their re-do rate for manipulation? I think the days are few before it is mandatory - does anyone (dis)agree?
Howard Simpson SpR A&E Salisbury, Wessex Rotation
I've always hated haematoma blocks because they often don't work well (in my
hands anyway - perhaps others do better !) and your "ouch" scenario seems
more familiar when using those.
Cheers,
Rob Cocks HK
-----Original Message-----
From: John Chambers [mailto:[log in to unmask]]
Sent: Friday, February 25, 2000 6:31 AM
To: [log in to unmask]
Subject: Bier's Block
Bier's Block is obviously safe
Just a shame it has such a high failure rate
To quote many a silly young doctor when the patient screams
as their broken
wrist is pulled and waggled "Did you feel that?....."
Analgesia +Midazolam (followed by Flumazenil) rules OK
They feel it but they don't give a damn!
JohnC
-----Original Message-----
From: Andres Izquierdo Martin [mailto:[log in to unmask]]
Sent: Thursday, 24 February 2000 11:16
To: Emergency List
Subject: Re: VT and acidosis
----- Original Message -----
From: Doc Holiday <[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, February 23, 2000 12:37 AM
Subject: Re: VT and acidosis
> Definition: Bier's Block
>
> A method for inducing arrhythmias in a patient who is "on
no medication,
had
> no prior history of heart disease, and who had a normal
pre-op ECG."
>
> Can't think of any other indications...
No much imagination if you cannot think of any other
indications.
Bier's Block is a safe and useful technique to use in an
emergency
department.
If you check the literature you will find many papers
comparing favourably,
Bier's Block with haematoma block.
The other possibility, of course , is general anaesthesia;
but I cannot
believe you think that this option is "arrhythmia free".
I think we would all be interested to know what is your
"risk free"
option.
Andres Izquierdo Martin
SpR Emergency Medicine
Royal Free Hospital
North East Thames Region
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