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In our department the haematoma block is our preferred choice of anaesthesia for displaced distal radial fractures in adults because: 1. It is simple and safe for junior clinicians 2. It provides effective analgesia IF properly performed 3. It can be performed as soon as the patient arrives in the ED 4. It can be performed in minor side without need for additional resources (monitoring/staff). 5. Infection is not a problem. 6. Satisfactory reduction can be achieved at least initially. We have regularly audited our practice and have been satisfied with the outcome. All our discharged patients are seen within 24 hours of the reduction by a consultant trauma surgeon 365 days a year. I have seen senior clinicians have significant complications with axillary nerve blocks and would not recommend its routine use in the ED. The logistics of undertaking a Bier's block in many of our local department frequently necessitates delayed reductions and a second reattendence for a primary procedure depending on the timing of presentation and capacity in the ED. The key to success with the haematoma block, as with any procedure, is the quality of the training. John Black Oxford -----Original Message----- From: Ray McGlone [mailto:[log in to unmask]] Sent: 30 September 2002 07:49 To: [log in to unmask] Subject: Re: Bier's Block Regarding the "allergic reaction" with Citanest the following is worth reading. The without preservative Prilocaine was primarily used for epidurals by orthopods in our area. Ray McGlone A&E Lancaster Authors Kajimoto Y. Rosenberg ME. Kytta J. Randell T. Tuominen M. Reunala T. Rosenberg PH. Institution Department of Anaesthesiology, Helsinki University Central Hospital, Finland. Title Anaphylactoid skin reactions after intravenous regional anaesthesia using 0.5% prilocaine with or without preservative--a double-blind study. Source Acta Anaesthesiologica Scandinavica. 39(6):782-4, 1995 Aug. Local Messages Held at BMA Library Abstract Methylparaben, the preservative of various local anaesthetic solutions, is a potential allergen. In a double-blind study, 0.5% prilocaine with (Citanest, n = 100) or without (n = 100) methylparaben were compared for the occurrence of skin reactions after intravenous regional anaesthesia of the arm in surgical patients. Skin reactions were registered after the deflation of the tourniquet cuff, and intradermal tests were performed with 0.5% prilocaine, 0.1% methylparaben and saline in all patients. Seventeen patients in the Citanest group and four patients in the methylparaben-free prilocaine group developed erythematous skin reactions in the exposed arm after deflation of the tourniquet cuff (P < 0.05, between the groups). The skin symptoms disappeared within an hour and were always restricted to the region which had been anaesthetised. None of the affected patients had positive intradermal tests. The observed skin reactions are probably non-IgE-mediated anaphylactoid reactions in which the presence of methylparaben in the local anaesthetic solution plays a major role. ----- Original Message ----- From: "Steve Meek" <[log in to unmask]> To: <[log in to unmask]> Sent: Sunday, September 29, 2002 10:29 PM Subject: Re: Bier's Block > been round the houses on this one Ray. Forced to > changhe to lignocaine when prilocaine without > preservative unavailable, mailed the list about it and > found some using prilocaine with preservative although > alleged risk of reaction, others still getting it > without preservative, others using lignocaine. > Reasonable anecdotal reports of widespread antepodean > use of ligno w/o problems. > I had several probs with lignocaine: useing > 200mg,failures due to insufficient doseage I think > with beefy forearms, and symptomatic reactions to cuff > leakage at the same dosage in other patients. Cuff > leak with prilocaine happened to me twice without > symptoms (to patients of mine I mean). > Now at Frenchay using prilocaine 1% diluted down to > 40mls )0.5% without problems......this variation in > supply across the region and reasons given for it > leaves me confused. > bottom line is, I am sure prilocaine is safer than > lignocaine and agree with Ray that it is then a safe > SHO procedure: staring patients, 2 doctors being > present etc is unneccessary > steve meek > frenchay > -- Ray McGlone <[log in to unmask]> wrote: > > We had a locum A&E Consultant in Lancaster from the > > deep south, who stated that many departments in > > London had stopped doing Bier's Blocks after Astra > > withdrew 0.5% Prilocaine. How many of you have > > stopped using Bier's block for this reason? > > > > 0.5% Prilocaine is still available from Switzerland > > (with German / French inserts!) and plain Prilocaine > > 0.5% in 10 ml ampoules is still available from a > > hospital sourse. The latter will have a shorter > > shelf life. > > > > Alternatively one can use 1% Prilocaine followed by > > a saline flush to preserve total volume injected but > > using the same dose of Prilocaine. Peter Cutting SpR > > presented the results of a study at the Edinburgh > > conference. > > > > Interestingly a found a paper implying that 0.75% > > Prilocaine was the best concentration... but Astra > > have probably not seen it! The authors would have > > been using Bier's block for a number of indications > > not just colles fracture manipulation. > > > > Authors > > > > Prien T. Goeters C. > > > > Institution > > > > Klinik und Poliklinik fur Anasthesiologie und > > operative Intensivmedizin der Westfalischen > > Wilhelms-Universitat Munster. > > > > Title > > > > [Intravenous regional anesthesia of the arm and foot > > using 0.5, 0.75 and 1.0 percent prilocaine]. > > [German] > > > > Source > > > > Anasthesie, Intensivtherapie, Notfallmedizin. > > 25(1):59-63, 1990 Feb. > > > > Abstract > > > > Quality of anaesthesia and risk of intoxication are > > competing principles in IVRA. To evaluate the > > optimal prilocaine concentration with injection of > > 40 ml, 300 patients were randomly allocated to > > receive either a 0.5 (PRI 0.5), 0.75 (PRI 0.5) or a > > 1.0 (PRI 1.0) per cent solution. Using PRI 0.5, > > fifteen patients required supplementary fentanyl, > > with PRI 0.75 one, and with PRI 1.0 two (p less than > > or equal to 0.05). General anaesthesia proved > > necessary in three patients of the PRI 0.5 and 0.75 > > groups, respectively, and in one patient of the PRI > > 1.0 group (NS). With PRI 1.0 seven patients had > > subjective signs of intoxication upon tourniquet > > release, with PRI 0.75 none, and with PRI 0.5 one (p > > less than or equal to 0.05). Objective symptoms of > > local anaesthetic toxicity were not observed. The > > incidence of tourniquet-related pain was 25-30% in > > all three groups and not related to the prilocaine > > concentration. In conclusion, with 40 ml injection > > volume the 0.75% solution of prilocaine offers the > > optimal relation between incidence of anaesthesia > > and risk of intoxication. > > > > > > > > Regards > > > > Ray McGlone > > > > A&E Consultant > > Royal Lancaster Infirmary / Westmorland General > > Hospital > > > > > http://www.mbha.nhs.uk/morecambe_bay_hospitals_trust.htm > > > > > __________________________________________________ > Do you Yahoo!? > New DSL Internet Access from SBC & Yahoo! > http://sbc.yahoo.com