ED AI Tutor — Bier's Block Visual Operating Manual

The Procedure at a Glance

Plate I — Setup & Cuff Placement

Step 1

Velband Padding

Wrap the upper arm in Velband to protect skin and distribute cuff pressure

Step 2

Cuff Secured

Position pneumatic cuff over padding • secure with Velcro and red ties • connect hose to wall air outlet

Mechanism

Tourniquet-occluded venous bed retains injected local anaesthetic in the affected limb, producing analgesia, muscle relaxation, and a bloodless field — without sedation or GA.

Why ED-Led IVRA

Reliable ED-led analgesia for distal forearm reductions when anaesthetic cover, theatre access, or sedation-capable staffing is constrained.

Non-Negotiables

Resus bay only. Two clinicians minimum. 1:1 nursing. Continuous monitoring. Lipid rescue at bedside. Cuff discipline.

INDICATIONS

▸Wrist / forearm fracture manipulation
▸Multiple forearm lacerations needing repair
▸Foreign body removal from forearm wounds

WORKFORCE

▸Minimum 2 doctors OR 1 doctor + NP
▸Doctor 1: drugs, monitoring, cuff
▸Doctor 2 / NP: manipulation
▸1:1 nursing throughout

LOCATION & SUPPORT

▸Resus bay only — full resus capability
▸Portable post-reduction X-ray pre-booked
▸Continuous ECG / NIBP / SpO₂
▸Lipid 20% drawn up ready

Six-Gate Pathway

GATE 1

SELECT

GATE 2

SCREEN

GATE 3

SETUP

GATE 4

BLOCK

GATE 5

REDUCE

GATE 6

RECOVER

Patient Eligibility Screen

Tick each contraindication that applies. The system blocks the procedure if any absolute CI is present, or flags caution at ≥ 2 relative CIs.

Absolute Contraindications

Hard stop

Relative Contraindications

Senior review

✓ PROCEED

No absolute contraindications and ≤ 1 relative. Proceed with consent, dose calculation, and equipment check.

Equipment Atlas

Visual reference for setup and equipment check.

Plate A — Skin Protection

Velband Padding

Wrap the upper arm in Velband before the cuff goes on. The padding protects the skin from pressure injury and ensures even cuff distribution. Wrap snugly but not tight.

Plate B — Tourniquet Cuff

Cuff Placement

Single pneumatic cuff positioned over the Velband. Secure with Velcro and the red ties (do not rely on Velcro alone). The hose runs to the wall air outlet via the controller.

Plate C — Pressure Regulator

Zimmer Inflatomatic 3000

Low-pressure nitrogen-powered tourniquet controller

1.Connect hose to the black air outlet on the wall.
2.Turn the device ON (switch to the right).
3.Slowly inflate the cuff by turning the pressure knob to the right.
4.Watch the upper gauge (cuff pressure) — target SBP + 100 mmHg, max 300 mmHg.
5.Confirm radial pulse absent. Document time on.

The cuff role is assigned to a named person. They check inflation continuously (look and feel) and don't leave the bedside.

Plate D — Vascular Access

Distal IV Access

A 22 G cannula in the dorsum of the affected hand — as distal as practical. Evidence suggests distal injection improves block quality.

▸22 G distal IV on the affected limb (block delivery)

▸Second IV on the unaffected limb (rescue access)

▸1 L of 0.9% saline primed and hanging on IV pole

▸Affected-limb cannula is removed after block onset (before manipulation)

Pharmacology — Six Drugs to Know

One agent for the block, five for the complications. Memorise every dose.

PRIMARY AGENT

Prilocaine 0.5% (Citanest)

Plate II

Role

Local anaesthetic agent — the block itself

Concentration

0.5% • 250 mg in 50 mL • 5 mg/mL

Dose

3 mg/kg IV (max 400 mg / 80 mL)

Clinical Note

Inject slowly via the distal IV in the affected limb after cuff inflation. Methaemoglobinaemia is the signature complication.

Complication Management

The Five Rescue Drugs

LAST RESCUE

Intralipid 20%

500 mL • Lipid emulsion

Dose
1.5 mL/kg bolus over 1 min • Infuse 15 mL/kg/hr

70 kg: 100 mL bolus then 300–400 mL over 15 min

METHAEMOGLOBIN

Methylene Blue 1%

50 mg in 5 mL

Dose
1 mg/kg slow IV over 10 min

Caution G6PD deficiency • Avoid > 7 mg/kg (paradoxical metHb)

LAST DYSRHYTHMIA

Sodium Bicarbonate 8.4%

8.4 g in 100 mL • Sodium channel antidote

Dose
1–2 mmol/kg IV • Repeat every 1–2 min until perfusing rhythm

For ventricular dysrhythmia, hypotension, seizures from LA toxicity. Extravasation → tissue necrosis.

SEIZURE CONTROL

Diazepam

10 mg in 2 mL • GABA-A modulator

Dose
5–10 mg IV • ≤ 5 mg/min • Repeat after 10 min

For LAST seizures. Watch for apnoea, hypotension, thrombophlebitis.

CARDIAC ARREST

Adrenaline 1:10 000

10 mL (1 mg) • Sympathomimetic

Dose
1 mg (10 mL) IV • Repeat q3–5 min in arrest

Reserve for cardiac arrest. Severe hypertension may precipitate cerebral haemorrhage / pulmonary oedema.

Dose & Cuff Calculators

Prilocaine 0.5% — Weight-Based Dose

Patient Weight (kg)

306090120 kg

Rule: 3 mg/kg • Maximum 400 mg (80 mL of 0.5%) • Volume = weight × 0.6 mL

Recommended Dose

210 mg

42.0 mL of 0.5% solution

Within max dose of 400 mg

Cuff Inflation Target

Patient Systolic BP (mmHg)

Rule: SBP + 100 mmHg • Maximum 300 mmHg • Single cuff

Cuff Timer & Safety Watch

Cuff Inflation

00:00

Since Prilocaine Injection

—:—

Min 25 min before any deflation

Safety Watch

Cuff timer idle

• 20 min minimum since prilocaine

• 25 min preferred — tissue binding

• 60 min review threshold

• 90 min hard upper limit

Procedure — Twelve Sequenced Steps

Photos integrated where they clarify the step.

Cuff Deflation Protocol — Cycled Release

Cycle 1

Deflate over 10 sec → reinflate for 1 min → observe for LAST

Cycle 2

If no toxicity, deflate again 10 sec → reinflate 1 min → observe

Final

Deflate fully and remove. Document time. Continue monitoring 15 min.

Local Anaesthetic Systemic Toxicity

Recognise early. Reinflate the cuff. Get help. Lipid rescue.

Symptom Cascade

Early CNS

• Peri-oral paraesthesia
• Metallic taste
• Tinnitus
• Dizziness
• Slurred speech

Progressing

• Twitching
• Fasciculations
• Visual disturbance
• Disorientation
• Drowsiness

Severe CNS

• Seizure
• Coma
• Respiratory arrest

Cardiac

• Hypotension
• Bradycardia
• Wide-complex arrhythmia
• Ventricular dysrhythmia
• Cardiac arrest

Always recheck cuff pressure — uninflated cuff = systemic release of LA

Rescue Algorithm

One-Look LAST Response

Step 1

RECOGNISE

• Peri-oral numbness
• Metallic taste
• Tinnitus
• Seizure
• Arrhythmia

Step 2

STOP & CALL

• Stop injection
• Reinflate cuff if deflated
• Call senior
• Activate resus team

Step 3

ABCs

• 100% oxygen
• Airway support
• ECG monitoring
• Diazepam for seizure

Step 4

LIPID RESCUE

• Intralipid 20%
• 1.5 mL/kg bolus over 1 min
• Infuse 15 mL/kg/hr
• Repeat bolus if needed

Step 5

ESCALATE

• ICU / anaesthetics
• NaHCO₃ 1–2 mmol/kg
• CPR + adrenaline if arrest
• Continue monitoring

Lipid Rescue — At the Bedside

Intralipid 20% 500 mL must be drawn up and visible before injection

If not present, do not proceed with the block.

Prilocaine-Specific

Methaemoglobinaemia

Recognise

• Cyanosis despite high-flow O₂
• Hypoxia, dyspnoea
• Chest pain, tachycardia
• Headache, confusion
• "Chocolate-brown" blood

First-Line

• High-flow O₂
• Recheck cuff still inflated
• Confirm with co-oximetry / VBG
• Senior support / ICU consult

Methylene Blue

• 1 mg/kg slow IV over 10 min
• Repeat at 1 h if cyanosis persists
• Caution G6PD deficiency
• Avoid > 7 mg/kg (paradoxical metHb)

Documentation Template

Every Bier's block needs a complete record — for safety, audit, and medico-legal protection.

Quality Indicators & Audit Targets

Process

• Patient selection rate
• Time to block from arrival
• Cuff-time breach %
• Documentation completeness

Outcome

• Reduction success
• Procedural sedation avoided
• ED length of stay
• Pain scores pre / post

Safety

• LAST incidents
• Met-Hb events
• Cuff failures
• Unplanned admissions

Audit & Quality Capture

Record each procedure for departmental quality review and continuous improvement.

Local Storage Mode — v0.4

Data is currently saved to this browser on this device only. Use anonymised identifiers (e.g. Pt-001) — never patient names or UR numbers. Export to CSV regularly for departmental records. Backend storage with multi-user access is planned for v0.6.

Total Cases

Success Rate

—

Adverse Events

—

Mean Cuff Time

—min

New Procedure Entry

Form

1. Procedure Metadata

Date

Operator (initials)

Site (optional)

2. Patient (anonymised)

Identifier *

Age

Sex

Weight (kg)

Limb

Indication

3. Block Parameters

Pre-SBP (mmHg)

Cuff Target (mmHg)

Cuff Inflation Time

Cuff Deflation Time

Cuff Duration (auto)

Prilocaine (mg)

Onset (min)

Block Quality

4. Outcome

Procedure Successful

Reduction Satisfactory

Pain Pre (0–10)

Pain Post (0–10)

Patient Satisfaction

5. Adverse Events (tick all that apply)

Other AE (free text)

6. Disposition & Notes

Disposition

Follow-up Arranged

Notes (free text)

Audit Log

Click any row to expand details. Saved locally on this device.

Date	Pt ID	Age	Indication	Cuff (min)	Quality	Outcome	AE	Actions
No entries yet. Complete the form above to start your audit log.

Resources & References

Source guidelines and further reading for Bier's Block and IVRA practice.

Clinical Reference

LITFL

Life in the Fast Lane

Comprehensive Bier's Block reference covering technique, drug doses, contraindications, and LAST management. FOAMed clinical reference written by Australian and New Zealand emergency physicians.

Visit litfl.com →

RCH

Paediatric Reference

RCH Melbourne

Clinical Practice Guidelines

Royal Children's Hospital clinical practice guidelines — local anaesthetic toxicity, pain management, and procedural sedation alternatives for children under 10 where Bier's Block is relatively contraindicated.

Visit rch.org.au →

SCG

Source Guideline

SCGH ED

Sir Charles Gairdner Hospital

Sir Charles Gairdner Hospital Emergency Department — origin of the Bier's Block guideline (updated by NP N. O'Mahony, reviewed by Dr J. Armstrong, June 2019) that this module synthesises.

Visit scgh.health.wa.gov.au →