Sorry if some of this is a re-hash.

Would not be surprised to find that there is more than one good solution for 
the Colle's blocks. I can't say I would criticise anyone for using a Bier's 
block if they are happy that they have achieved best results with it. Still, 
I don't like it and have not done any for 10 years now, except once, when I 
came to a locum jobbie and found this amazing colourful dual torniquet cuff 
(and that once it actually worked). With such a minimal background in Bier's 
blocks, I have to say I do not dislike them for their lack of success - I 
have not done enough to have a failure, even when I did do them...

As for the alternative, for which list members have asked, "warning" in 
advance against me saying it was the haematoma block... I'm afraid I only 
read my mail once a week and, by now, some have already mentioned my 
favourite - Axillary Block.

I have a few things to say about it:
1. Have never done an Inter-Scalene block, so cannot comment. I do an 
axillary block in the axilla...
2. My preference (similar to 40ml 1% Lignocaine) is to mix 20ml and same 
volume of Bupivacaine 0.5% (one of these with Adrenaline). I usually inject 
only 30ml of the resulting mix and keep the rest just in case...
3. It's a great technique to master, but even then, as stated, it will 
occasionally fail. But it has more uses, for which neither Bier's nor 
Haematoma blocks will do, e.g. major forearm burns for dressing/surgery, 
tendon work (if you're going to take long and have haemostasis), etc... Have 
even done a nasty elbow #/disloc with it once as a junior SHO with a senior 
colleague while out on Safaari in Africa - the local clinic had no 
electricity and no decent torniquet and we had to choose what we though 
would be least risk...
4. It provides LONG analgesia.
5. As already mentioned - do the X-ray while it "cooks".
6. In common with haematoma block, there are no torniquet failures (our 
commonest torniquet failure is the failure to find a working one). There is 
also no problem is you need counter traction and cannot find a place to hold 
with the toeniquet in the way (minor nit pick).

Having said that - I do most of mine with haematoma block and teach juniors 
this method mostly, as it's the easiest. I try to emphasize good (opiate IM) 
analgesia before X-ray, so that the patient is comfortable there and during 
injection.

In the old days we used "3rd world stuff" - the simple bits - to make things 
better: We put Emla on the proposed injection site, then a big ice pack and 
IM morphine, then X-ray, then only remove the ice at the time of injection. 
Patients feel nothing!! As Danny said, make sure you find the haematoma and 
inject the styloid area (I do even if it does not seem broken), although 
most times the haematoma extends there. Inject slowly and hurt lessly... So 
I do not agree with haematoma block critics about the pain issue.

No harm in a smidge of Midaz even before haematoma/axillary block if patient 
still tense - makes them happy... And Midaz IS safe if used safely.

Last, to those who got into the debate of how to empty out the limb, then 
fill it up, then empty again... For the Bier's block, that is. Please tell 
me, those who say they lift the arm or squeeze it in rubber, how they get 
rid of the pain at the fracture site while doing that? (I'm not sarcastic - 
I really wish to know) This, I find, is the one thing better about haematoma 
block - you can do it in the sling they put on at triage, without much 
movement. Axillary slightly more difficult.

Having got that off my chest... Does anyone out there, as I do, miss having 
an image intensifier for these?

And... What do you tell an SHO about displaced distal radius fractures in 
fit young patients when they need reduction? Do you let them do it? Call for 
help? Refer? Any modifications from the old folks' Colles?

drydok


______________________________________________________
Get Your Private, Free Email at http://www.hotmail.com



%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%