Improving Outcomes, Mythbusting

Bier me, STAT!

For distal radius fractures, hematoma blocks are cruel. Think about it: you are injecting several CC’s into a fresh, painful, fracture site. I have yet to see a patient * not * cringe, no matter who does the block. To top this all off, I have yet to see it provide adequate analgesia during reduction. So, not only are we making them miserable by providing an injection into their fracture, we are then manipulating them-sometimes more than once- after not providing significant analgesia. It’s not really a nice thing to do. I’ve seen mid-levels, ED attendings, and orthopods all do this with pretty much the same results.  The definition of insanity if doing the same thing repeatedly and expecting a different result. So let’s try and stop the insanity by having a Bier (block).

Doing a literature dive, let’s start by saying there is an overblown concern over lidocaine toxicity. In a study of 1816 Bier blocks by anesthesia for hand surgery, there were 9 adverse reactions (1 medical error, 3 with improper cuff inflation, 5 with inadequate analgesia). None of the adverse reactions resulted in failure to complete the procedure or in serious morbidity / mortality. A second study of 416 patients showed no morbidity or mortality, but 39 episodes of transient hypotension or bradycardia of which none required an intervention. A third study was done on 484 patients. The block was ineffective for 1 patient, tourniquet related problems were reported in 5 patients, but no anesthetic toxicity. The block was given by the operating surgeon and not by anesthesia – thus it is likely safe for ED providers to perform.

Now let’s compare it to hematoma blocks. Over four studies looking at over 400 patients total, there is significantly more pain during manipulation with hematoma block than with a Bier’s block, and the Bier’s block had fewer re-manipulations, better pain control, and better radiological outcome.

Lastly, there is a modified Bier’s Block involving a single tourniquet. In comparison to the two tourniquet technique, there is no significant difference between forearm and conventional Bier’s block for pain control, and no major complications, looking at three different studies, totaling about 150 patients. Patients were also given less lidocaine in the forearm group (160mg vs 300mg).

So, there you have it. The Bier’s block is safe and more effective than a hematoma block for distal radius fractures, and you can even use a single tourniquet rather than two pneumatic cuffs. So go ahead, enjoy a Bier with your patient.

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PMID: 17123673
PMID: 17324303
PMID: 23407261
PMID: 23508563
PMID: 20122591
PMID: 18040193
PMID: 22627706
PMID: 3935242
PMID: 3893460
PMID: 2205997
PMID: 9413772

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