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 ties • connect hose to the controller

Mechanism

Dilute local anaesthetic injected into the venous system of a limb that has been exsanguinated and isolated by a pneumatic tourniquet. Produces analgesia, muscle relaxation and a bloodless field without sedation or GA.

Why ED-Led IVRA

Avoids after-hours theatre activation, avoids the risks of deep procedural sedation, and avoids transfer of patients whose distal forearm fracture could be definitively managed locally.

The Whole Safety Case

The entire safety of this technique rests on the cuff. The injected dose is systemically toxic if released before the drug is tissue-bound.

Evidence Markers Used Throughout

●Guideline-supported — recommended by a college or society guideline

◐Limited or observational — cohort, case series or survey data only

○Expert consensus — no direct evidence for the specific recommendation

The evidence base for IVRA is old, largely observational, and thin on the procedural details that protocols dispute. These markers let you tell a genuinely evidence-based requirement from a convention.

In Scope — Adult Distal Upper Limb

▸Manipulation of distal radius and distal forearm fractures
▸Reduction of wrist dislocations
▸Repair of extensive forearm or hand lacerations where infiltration is impractical
▸Foreign body removal from forearm or hand wounds

Out of Scope

✕Lower limb IVRA — tourniquet reliability, LA volumes and complication rates all less favourable
✕Forearm (below-elbow) cuff technique — promising in surgical literature, not established for ED fracture manipulation
✕IVRA as a treatment for complex regional pain syndrome
✕Children under 8 — see the Eligibility tab

Minimum Staffing

▸Operator 1 — block clinician: consent, dose, drug administration, cuff supervision, LAST response. Does not perform the manipulation.
▸Operator 2 — proceduralist: manipulation or wound procedure, plaster.
▸Nurse: ALS-competent, 1:1, verifies cuff pressure against the set value, documents times.

Location & Support

▸Resus bay only — full resuscitation capability
▸Radiography notified in advance; portable post-reduction film with the cuff still inflated
▸Continuous ECG, SpO₂ and respiratory rate; NIBP on the unaffected arm every 5 min
▸Nurse in Charge informed before starting

Credentialling ●

▸Current ALS/ACLS certification
▸Departmental theory package including LAST management
▸Familiarity with the specific tourniquet device — self-test, alarms, failure modes
▸Three supervised procedures signed off by a FACEM or credentialled senior
▸Recredentialling every 2 years, or after 12 months without performing it

Cuff Watch — Assigned Aloud

One named person holds continuous responsibility for the cuff and does not leave the bedside or take on a competing task until the cuff is finally deflated. This is assigned aloud at the pre-procedure pause and recorded.

Slow unintentional deflation is the principal failure mode. Tourniquet dials stay under observation at all times.

Low-Volume Risk — The Principal Regional Hazard

Where this procedure is performed infrequently, skill and equipment familiarity decay faster than at a high-volume site — and the failure mode that matters (cuff mismanagement) is exactly the one experience protects against.

The credentialled register, mandatory checklist and recredentialling interval are the controls for this. They are not to be waived for convenience or workload.

Choice of Technique

Bier's Block Compared With the Alternatives

Technique	Evidence Position	Role
Bier's block (IVRA)	RCEM best-practice guideline recommends IVRA over haematoma block — haematoma block gives less analgesia and may compromise reduction. Comparative cohort data (Oakley 2023) support superior analgesia.	First line
Haematoma block	Less analgesia; risk of introducing infection into the fracture site. Still widely used because it is quicker and needs no special equipment.	Alternative when IVRA contraindicated or declined
US-guided supraclavicular block	SUPERB (Tsao 2025, EMA) — Australian open-label non-inferiority RCT, 78 patients: non-inferior to Bier's block for procedural pain, with longer post-procedure analgesia. Single-site; phrenic paresis reported in a companion cohort.	Emerging — requires a POCUS-credentialled operator
Procedural sedation	Effective but carries airway, aspiration and haemodynamic risk; longer recovery and higher staffing burden.	Reserve for block failure or contraindication
Theatre / GA	Definitive where operative fixation is indicated.	Orthopaedic referral pathway

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. Any absolute contraindication is a hard stop. Any single relative contraindication requires consultant discussion — two or more should generally prompt an alternative technique.

Absolute Contraindications

Hard stop

Relative Contraindications

Consultant discussion

✓ PROCEED

No contraindications identified. Proceed with consent, dose calculation and equipment check.

Why the threshold changed. An earlier convention allowed a single relative contraindication to proceed unreviewed, escalating only at two. That threshold has no published basis and would allow, for example, a patient with epilepsy to proceed without senior input to a procedure whose sentinel complication is a seizure.

○ Expert consensus — no direct evidence

Refusal of Rescue (Contralateral) IV Access

No published guideline addresses informed refusal of the second cannula. The position below is a governance decision, not an evidence-based one, and is stated explicitly so it can be debated.

A competent, fully informed adult may decline any component of a procedure. But declining rescue IV access is different in kind from declining an adjunct: it removes the only route by which lipid emulsion, benzodiazepines and resuscitation drugs can be given if the cuff fails. The clinician is not obliged to perform a procedure whose rescue pathway has been removed.

▸Explain that the second cannula exists to treat a rare but potentially fatal complication, and that in an emergency there may be no time to obtain access
▸Offer alternatives — haematoma block, procedural sedation (which itself needs IV access), or referral for theatre

✕If refusal is maintained, do not proceed. Document the discussion, risks explained, alternatives offered and the decision
▸Difficulty obtaining access is not refusal. Escalate for ultrasound-guided cannulation before abandoning the procedure

Before You Start

Consent

Verbal consent is the minimum. Written consent is preferred, and required if any relative contraindication is present. Consent must cover:

▸The nature of the procedure and that the patient will be awake throughout

▸Expected sensations — cuff tightness and discomfort, warmth or tingling, limb mottling

▸The requirement to remain still with the cuff inflated for 25–45 minutes

▸Common transient after-effects — tinnitus, dizziness, light-headedness, drowsiness after deflation

▸The rare but serious risk of LAST including seizure and cardiac arrest — and that this is why two cannulae, continuous monitoring and a rescue kit are required

▸Alternatives — haematoma block, procedural sedation or theatre — and their relative risks

● Guideline-supported — RCEM; O'Sullivan 1996

Fasting is not required. The procedure is not delayed for fasting status.

○ Expert consensus — no direct evidence

Children

Bier's block is established in paediatric practice and RCH maintains a guideline for it. The age thresholds below are a local decision based on cooperation, cuff fit and case volume. They are not a methaemoglobinaemia threshold and should not be described as one — the only sourced age limit relating to prilocaine and methaemoglobinaemia is 6 months, reflecting enzyme immaturity in infants.

Under 8 years

Not to be performed. Use procedural sedation, or discuss with the paediatric retrieval service and the receiving orthopaedic team.

8–15 years

Only with a FACEM physically present, using RCH parameters, and only where the child is demonstrably cooperative after explanation.

16 and over

Managed as an adult under this protocol.

Paediatric parameters (RCH) — these differ from the adult protocol
Agent	Lignocaine 0.5% (dilute 1% with an equal volume of sodium chloride 0.9%) — not prilocaine
Dose	3 mg/kg = 0.6 mL/kg of 0.5% — maximum 200 mg / 40 mL
Cuff pressure	Systolic BP + 75 mmHg, maximum 250 mmHg — lower than the adult target
Cuff time	Not before 20 minutes and not later than 45 minutes after injection
Additional	Topical anaesthetic cream before cannulation; adequate analgesia of the underlying injury first; parent present

Weight-based lipid emulsion and midazolam doses for the child must be calculated and written down before the block begins.

Equipment Atlas

Visual reference for setup and equipment check. If the tourniquet fails its self-test or a leak is detected, the procedure does not proceed — the cuff is the sole safety mechanism.

Plate A — Skin Protection

Velband Padding

Wrap the upper arm in orthopaedic wool before the cuff goes on. The padding protects skin from pressure injury and distributes cuff pressure evenly. Wrap snugly but not tight.

Plate B — Tourniquet Cuff

Cuff Placement — Upper Arm, Single Cuff

Positioned over the padding on the upper arm — adequate arterial compression is not achievable at the forearm. Secure with Velcro and ties (do not rely on Velcro alone). Route tubing away from the operative field.

Plate C — Pressure Regulator

Zimmer Inflatomatic 3000

Low-pressure nitrogen-powered tourniquet controller

1.Power on and complete the self-test. Inflate and deflate the cuff to confirm integrity; inspect cuff and tubing for leaks.
2.Connect the hose to the wall air outlet via the controller.
3.Set the cuff target pressure and the device minimum time before inflating for the block.
4.Watch the gauge — target SBP + 100 mmHg, maximum 300 mmHg. Do not exceed the calculated target: higher is not safer.
5.Confirm the radial pulse is absent before injecting. Record inflation time and pressure achieved.

Guay reports LAST occurring during inflation where cuff pressure exceeded systolic by 150 mmHg. Over-inflation is its own hazard.

Plate D — Vascular Access

Two Cannulae — Always

A 22 G cannula in the dorsum of the affected hand, sited as distally as practicable — distal injection improves block quality.

▸22 G distal IV on the affected limb — block delivery

▸Rescue cannula on the unaffected limb — the only route for lipid, benzodiazepine and resuscitation drugs

▸1 L sodium chloride 0.9% primed on a rapid giving set at the bedside

▸Affected-limb cannula is removed after block onset, with prolonged direct pressure — the site oozes because of venous congestion

✕Do not remove the rescue cannula until the full post-deflation observation period is complete and the patient is asymptomatic

Equipment Checklist

Pneumatic tourniquet with dedicated controller — self-tested, inflated and deflated, no leak
Limb padding (orthopaedic wool) sufficient to protect skin under the cuff
Two IV cannulae — 22 G recommended for the affected limb; confirm access is obtainable on the unaffected arm
1 L sodium chloride 0.9% primed on a rapid giving set at the bedside
Oxygen, suction, bag-valve-mask, airway trolley and defibrillator — checked and present
Plaster trolley and post-reduction immobilisation materials

Monitoring

▸Continuous ECG, SpO₂ and respiratory rate — from before inflation until at least 15 min after final deflation
▸NIBP on the unaffected arm, cycling at least every 5 minutes
▸Baseline observations and a documented neurovascular examination of the affected limb before the block

● Guideline-supported — ASRA

LAST Rescue Kit

A sealed, labelled rescue kit at a fixed, published location in the resus area. Its location is stated aloud and confirmed at the pre-procedure pause. It contains:

▸Lipid emulsion 20% — 1000 mL total (2 × 500 mL bags)
▸Large syringes, drawing-up needles and a standard IV giving set
▸Laminated LAST action card

Methylene blue 1%, midazolam and adrenaline are held in ED imprest and their location confirmed at the same pause.

Antidotes are stocked and mapped — not drawn up in advance.

Pre-drawing generates wastage, sterility and labelling risk, and does not address the actual rate-limiting step in LAST, which is recognition and correct dosing rather than drawing-up time.

The absence of a pre-drawn syringe is not a reason to abandon an otherwise appropriate block. The absence of a stocked, locatable kit is.

Pharmacology — Six Drugs to Know

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

Absolute Agent Rules

✕Never adrenaline-containing preparations. Injecting a vasoconstrictor into an exsanguinated, tourniqueted limb prolongs ischaemia and delivers a systemic adrenaline bolus on cuff release.
✕Never preservative-containing solutions — they cause thrombophlebitis.
✕Never bupivacaine, levobupivacaine or ropivacaine. Bupivacaine was withdrawn from this indication in 1983 following deaths.

● Primary agent — guideline-supported (RCEM)

Prilocaine 0.5% (Citanest)

Plate II

Presentation

0.5% plain • 250 mg in 50 mL • 5 mg/mL • no adrenaline, no preservative • ARTG 12079

Dose

3 mg/kg = 0.6 mL/kg

Maximum 250 mg (50 mL) — one vial. Do not exceed one vial for an upper limb block regardless of body weight. This caps the dose at 3 mg/kg up to 83 kg, and below 3 mg/kg above that.

Administration

Slow injection over at least 90 seconds through the distal cannula — only after cuff inflation is confirmed and the radial pulse is absent.

Onset

5–10 minutes; may be longer

Why prilocaine

In Guay's systematic review of IVRA complications, cardiac arrests and deaths were reported with lignocaine and bupivacaine only — none with prilocaine. The lowest dose associated with a seizure was 4 mg/kg for prilocaine versus 1.4 mg/kg for lignocaine. Methaemoglobinaemia is the signature complication, but usually only above 16 mg/kg.

◐ Second line — limited / observational evidence

Lignocaine 0.5% — only if prilocaine is unavailable

RCEM records that during a UK prilocaine shortage, plain lignocaine 0.5% at 3 mg/kg to a maximum of 200 mg was an acceptable alternative, and RCH uses lignocaine as its standard paediatric agent. But Guay attributes all reported IVRA cardiac arrests and deaths to lignocaine or bupivacaine. Lignocaine is a fallback, not an equivalent.

▸Lignocaine 0.5% plain — preservative-free, adrenaline-free
▸If only 1% is stocked, dilute with an equal volume of sodium chloride 0.9%. Two-person independent check of the dilution is mandatory.

▸3 mg/kg to an absolute maximum of 200 mg (40 mL of 0.5%) — note this ceiling is lower than for prilocaine
▸Requires consultant approval on each occasion, with the reason for prilocaine unavailability documented

Complication Management

The Five Rescue Drugs

LAST RESCUE ●

Lipid Emulsion 20%

2 × 500 mL in the rescue kit • ASRA 2020 dosing

Under 70 kg
1.5 mL/kg bolus over 2–3 min, then 0.25 mL/kg/min infusion

70 kg and over
100 mL bolus over 2–3 min, then 200–250 mL over 15–20 min

No response → repeat the bolus or double the infusion rate. Upper limit ≈ 12 mL/kg total. Continue at least 10 min after haemodynamic stability. Do not delay for diagnostic certainty — the order of bolus versus infusion is not critical; early administration is.

Cautions: egg, soy or peanut hypersensitivity; severe hepatic impairment. In cardiac arrest these do not override the indication.

METHAEMOGLOBIN

Methylene Blue 1%

ED imprest — location confirmed at the pause

Dose
1 mg/kg IV over 5–10 min — if MetHb > 20% and symptomatic

May be repeated once after 30–60 min if features persist • Contraindicated in G6PD deficiency (haemolysis) • Never exceed 7 mg/kg — paradoxical methaemoglobinaemia • Potent MAO inhibitor: serotonin syndrome risk with SSRI / SNRI / MAOI, seek toxicology advice

SEIZURE CONTROL ●

Midazolam

5 mg in 1 mL • GABA-A modulator • Resus S4 drawer

Dose
2.5–5 mg IV, repeated as required

Benzodiazepines are the agent of choice for LAST seizures. Avoid propofol if there is any cardiovascular instability. Watch for respiratory depression and hypotension.

CARDIOVASCULAR — LAST IS NOT STANDARD ALS

Adrenaline — REDUCED DOSE

1:10,000 = 100 microgram/mL

Dose
1 microgram/kg or less — give 0.5–1 mL (50–100 microgram) boluses in an average adult, titrated to response. NOT 1 mg.

◐ ASRA advises boluses below 1 microgram/kg: standard doses produced worse outcomes than lipid emulsion in animal models of LA-induced arrest and impair the efficacy of lipid rescue. APSF describes high-dose adrenaline and vasopressin as counterproductive. Escalate only if there is no response to reduced dosing plus lipid.

LAST DYSRHYTHMIA

Amiodarone

Antiarrhythmic of choice in LAST

Use
Ventricular arrhythmia in LAST — amiodarone per ALS dosing. Defibrillate as per ALS.

Do not give

Vasopressin · calcium channel blockers · beta blockers · any further local anaesthetic including lignocaine as an antiarrhythmic · propofol as a vasodilating sedative in an unstable patient

Sodium bicarbonate is not an antidote in LAST and is not part of the ASRA algorithm — that is the tricyclic overdose regimen. Consider only for documented severe metabolic acidosis, on senior advice.

Dose & Cuff Calculators

Adult upper limb only. Deterministic — every figure below is calculated from the weight and systolic pressure you enter, not estimated.

Prilocaine 0.5% — Weight-Based Dose

Patient Weight (kg)

306090120 kg

Rule: 3 mg/kg = 0.6 mL/kg of the 0.5% solution • Absolute maximum 250 mg (50 mL) — one vial. Above 83 kg the dose is capped at one full vial; do not open a second.

Recommended Dose

210 mg

42.0 mL of 0.5% solution

Within the 250 mg single-vial maximum

Inject slowly over at least 90 seconds through the distal cannula, after cuff inflation is confirmed and the radial pulse is absent.

40 kg

120 mg

24 mL

50 kg

150 mg

30 mL

60 kg

180 mg

36 mL

70 kg

210 mg

42 mL

80 kg

240 mg

48 mL

Lipid Emulsion 20% — Rescue Dose for This Patient

● ASRA 2020 • Calculated from the weight above

Calculate this before the block and state it aloud at the pre-procedure pause. The rescue kit is stocked and mapped — not drawn up in advance.

Initial Bolus

100 mL

Over 2–3 minutes

Then Infusion

200–250 mL over 15–20 min

Ceiling

Approximately 840 mL total (≈ 12 mL/kg). If no response, repeat the bolus or double the infusion rate. Continue at least 10 min after haemodynamic stability.

Cuff Inflation Target

Patient Systolic BP (mmHg)

Rule: SBP + 100 mmHg • Maximum 300 mmHg • Single cuff. Do not exceed the calculated target — higher is not safer.

Single cuff, not double. RCEM recommends a double cuff to permit rotation; a single-cuff configuration eliminates the risk of deflating the wrong cuff — the more likely error in a low-volume department. Accepted trade-off: no rotation option for cuff pain, so procedures must be kept short.

Cuff Timer & Safety Watch

All timing for deflation runs from the injection time, not the inflation time.

Cuff Inflation

00:00

Max 45 min • 60 min ceiling with FACEM approval

Since Prilocaine Injection

—:—

Minimum 20 min before any deflation • 25 min preferred

Safety Watch

Cuff timer idle

• 20 min minimum since injection — tissue binding (25 preferred)

• Cycled release: 10 s down, 60 s up, observe

• Cycling unnecessary once cuff time exceeds 40 min

• 45 min maximum inflation time

• 60 min absolute ceiling, FACEM approval only

Children 8–15 years — FACEM present, RCH parameters

These calculators do not apply to children

Agent

Lignocaine 0.5% — not prilocaine

Dose

3 mg/kg = 0.6 mL/kg • max 200 mg / 40 mL

Cuff pressure

SBP + 75 mmHg • max 250 mmHg

Cuff time

Not before 20 min, not later than 45 min after injection

Procedure — Twelve Sequenced Steps

The pre-procedure checklist is completed and the pause performed aloud before any drug is drawn up. Photos integrated where they clarify the step.

○ Expert consensus — no direct evidence

Cuff Deflation Protocol — Cycled Release

Cycled deflation does not appear in the RCEM or RCH guidelines. It appears in anaesthetic texts and some hospital protocols, with a pharmacokinetic rationale — limiting peak plasma concentration — but no randomised or cohort evidence of benefit. It is retained as a low-cost precaution, deliberately bounded, and is not an evidence-based step.

Confirm First

Minimum 20 minutes since the injection (target 25) — not since cuff inflation. Warn the patient about tinnitus, dizziness or transient drowsiness and to report any symptom immediately.

Cycled Release

Deflate for 10 seconds → reinflate for 60 seconds → observe. If no features of toxicity, deflate fully.

Over 40 min

Where total cuff time already exceeds 40 minutes, cycling is unnecessary — a single controlled deflation is appropriate. Record final deflation time and total cuff time.

If toxicity appears at any point during deflation: reinflate the cuff immediately to the original target pressure and manage as LAST.

When It Doesn't Go To Plan

Block Failure & Intraprocedural Problems

Problem	Response
Inadequate block after 10 minutes	Confirm cuff pressure and absent pulse. Allow a further 5 minutes. Do not give additional local anaesthetic. If still inadequate, abandon and deflate after the minimum 20 minutes has elapsed, then plan an alternative.
Cuff pain	Expected — and the reason procedures are kept short. With a single cuff there is no rotation option. Reassurance and small-dose IV opioid if required, with continued monitoring. Complete the procedure promptly.
Premature or accidental cuff deflation	Reinflate immediately to target pressure. Treat as a LAST event until proven otherwise — continuous monitoring, prepare lipid emulsion, escalate to the consultant. Do not proceed with the manipulation. Incident report.
Unsatisfactory reduction on check film	One further manipulation attempt may be made if within the 45-minute ceiling. Otherwise deflate, observe, and refer to orthopaedics.
Patient distress or inability to remain still	Do not add sedation to an in-progress Bier's block as a routine rescue. Complete or abandon the procedure, deflate at the minimum time, and reassess.

After the Cuff Comes Down

Recovery, Observation & Discharge

Observation

▸1:1 nursing with continuous monitoring for 15 minutes after final deflation — the nurse remains with the patient
▸Total observation of at least 60 minutes from final deflation before discharge, with neurovascular observations every 15 minutes
✕Do not remove the rescue cannula until the full observation period is complete and the patient is asymptomatic
▸Repeat and document neurovascular examination of the affected limb
▸Confirm the plaster is not constricting; provide written plaster care advice

Discharge Criteria — All Must Be Met

Sensation returning, with intact neurovascular status distal to the cast
Observations stable; no features of toxicity at any point in the observation period
Satisfactory post-reduction imaging, reviewed and documented
Orthopaedic follow-up arranged, ideally within one week
Adequate analgesia supplied, with written and verbal advice on when to return
Social circumstances assessed — can manage at home with a plastered limb, or observation admission arranged

Delayed presentation of LAST is recognised. Discharge advice must explicitly instruct the patient to return immediately if they develop peri-oral numbness, metallic taste, tinnitus, visual disturbance, twitching, palpitations or breathlessness.

Local Anaesthetic Systemic Toxicity

Recognise early. Check the cuff. Get help. Lipid rescue. LAST is not standard ALS.

Two Things This Page Does Not Endorse

Two commonly circulated recommendations — standard 1 mg adrenaline boluses, and sodium bicarbonate as a sodium-channel antidote — are not endorsed here, because they conflict with ASRA and ANZCA/AAGBI guidance on LAST. Generic ALS dosing was not written for local anaesthetic toxicity, and bicarbonate is the tricyclic overdose regimen.

Symptom Cascade

LAST may present at any time from injection until well after deflation. The classic progression is CNS excitation → CNS depression → cardiovascular collapse — but cardiovascular features may occur first, and a seizure may be the first sign.

Early CNS

• Peri-oral / tongue numbness
• Metallic taste
• Tinnitus
• Dizziness, visual disturbance
• Slurred speech
• Anxiety, restlessness

Progressing CNS

• Muscle twitching
• Fasciculation
• Tremor
• Disorientation
• Drowsiness

Severe CNS

• Seizure
• Coma
• Respiratory arrest

Cardiovascular

• Hypotension
• Bradycardia
• Conduction block
• Wide-complex / ventricular arrhythmia
• Asystole, cardiac arrest

Always recheck the cuff — an uninflated cuff is the commonest cause and the fastest thing to correct

Rescue Algorithm — STOP · CUFF · AIRWAY · LIPID

One-Look LAST Response

Step 1

STOP & CALL

• Stop injecting
• Call for help
• Activate the resuscitation team
• Inform the ED consultant

Step 2

CHECK THE CUFF

• If deflated or deflating, reinflate immediately
• Return to the original target pressure
• Commonest cause, fastest correction

Step 3

AIRWAY

• 100% oxygen
• Support ventilation, prepare to intubate
• Hypoxia and acidosis worsen cardiac toxicity
• Seizures: midazolam 2.5–5 mg IV, repeat as needed

Step 4

LIPID RESCUE

• Lipid emulsion 20%
• < 70 kg: 1.5 mL/kg over 2–3 min, then 0.25 mL/kg/min
• ≥ 70 kg: 100 mL over 2–3 min, then 200–250 mL over 15–20 min
• Do not wait for diagnostic certainty

Step 5

CARDIOVASCULAR

• Adrenaline 1 microgram/kg or less
• Amiodarone for VT/VF; defibrillate per ALS
• Prolonged CPR is justified
• Call ARV early — retrieval, consider ECMO centre

Lipid Rescue — Stocked and Mapped

1000 mL of lipid emulsion 20% in a sealed rescue kit at a published location

Location stated aloud and confirmed at the pre-procedure pause. Antidotes are not drawn up in advance — but if the kit is not stocked and locatable, do not proceed with the block.

● Guideline-supported — ASRA / APSF

Cardiovascular Support — Where LAST Differs From ALS

Adrenaline	REDUCED boluses — 1 microgram/kg or less. Practically: 1:10,000 (100 microgram/mL), give 0.5–1 mL (50–100 microgram) in an average adult, titrated to response. Escalate only if there is no response to reduced dosing plus lipid.
Ventricular arrhythmia	Amiodarone is the antiarrhythmic of choice. Defibrillate as per ALS.
Hypotension	Crystalloid, lipid emulsion, reduced-dose adrenaline
Avoid	Vasopressin · calcium channel blockers · beta blockers · any further local anaesthetic including lignocaine as an antiarrhythmic · propofol as a vasodilating sedative in an unstable patient
Sodium bicarbonate	Not an antidote in LAST and not part of the ASRA algorithm. Consider only for documented severe metabolic acidosis, on senior advice.
Prolonged resuscitation	Continue CPR — recovery after prolonged arrest is documented. Contact ARV early (1300 368 661); consider retrieval and, in a metropolitan centre, extracorporeal support.

After any event: monitor at least 2 hours after an isolated CNS event, and at least 4–6 hours after any cardiovascular instability. Admit — do not discharge from ED. Contact ARV for advice and transfer if there has been any cardiovascular involvement. Complete an incident report; review at ED M&M and report to the Medication Safety Committee.

● Prilocaine-specific — risk is very low at 3 mg/kg

Methaemoglobinaemia

RCEM notes that prilocaine-induced methaemoglobinaemia usually occurs at doses above 16 mg/kg. At the 3 mg/kg dose used here the risk is very low. The group at genuine risk is infants under 6 months, because of immature methaemoglobin reductase activity and fetal haemoglobin — a group excluded from this protocol on other grounds.

Recognise

• Cyanosis that does not correct with high-flow oxygen — the cardinal sign
• Saturation plateauing around the mid-80s regardless of oxygen
• Headache, dizziness, fatigue, breathlessness
• Chest pain, tachycardia, confusion
• "Chocolate-brown" blood

First-Line

• High-flow oxygen
• Confirm the cuff is still inflated if the block is in progress
• Blood gas with co-oximetry — standard pulse oximetry is unreliable
• Involve the ED consultant
• Victorian Poisons Information Centre 13 11 26

Methylene Blue 1%

• 1 mg/kg IV over 5–10 min if MetHb > 20% and symptomatic
• May repeat once after 30–60 min if features persist
• Contraindicated in G6PD deficiency — consider ascorbic acid on toxicology advice
• Never exceed 7 mg/kg — paradoxical metHb by direct oxidation
• SSRI / SNRI / MAOI — serotonin syndrome risk
• Transient blue skin, urine and mucosa and a spurious low SpO₂ are expected, not deterioration

Appendix B — Laminate and store with the rescue kit

LAST Action Card

One team member reads this aloud during an event.

STOP

Stop injecting. Call for help. Activate the resuscitation team. Inform the ED consultant.

CUFF

Check the cuff. If deflated or deflating, reinflate immediately to the original target pressure.

AIRWAY

100% oxygen. Support ventilation. Prepare to intubate. Seizures: midazolam 2.5–5 mg IV, repeat as needed.

LIPID

Lipid emulsion 20% — give early, do not wait for diagnostic certainty.

Checklist & Documentation

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

Appendix A

Pre-Procedure Checklist & Pause

Completed aloud, by the block clinician, with all team members present — before any drug is drawn up.

0 of 0 complete

All timing for deflation runs from the INJECTION time, not the inflation time.

Documentation Template

Recorded in the medical record for every Bier's block.

● Guideline-supported — RCEM requires monitoring by audit, incident review, clinician feedback and complaints

Quality Indicators & Audit Targets

Safety

• LAST events
• Methaemoglobinaemia events
• Premature cuff deflation
• Cuff time outside 20–45 min

Target: zero; every event reviewed at M&M

Process

• Pre-procedure checklist completed
• Documentation completeness
• Performed by credentialled staff

Target: 100%

Effectiveness

• Adequate block achieved
• Satisfactory reduction on check film
• Conversion to sedation or theatre

Target: block success above 90%

Service

• ED length of stay
• Procedural sedation avoided
• Transfers avoided
• Patient-reported pain and satisfaction

Monitored, trend reported annually

Workforce

• Number of credentialled staff
• Individuals performing fewer than one procedure per year

Sufficient roster coverage maintained

Audit data are collected prospectively using anonymised identifiers and reviewed six-monthly. Any data collection tool must be assessed against local information governance requirements before use — the combination of date, site, age, sex and injury is potentially re-identifying in a small department, even without a name or UR number.

Appendix C — draft wording, health-literacy check before use

Patient Information — "Having a Bier's Block"

What is it?

A way of numbing your arm so we can straighten a broken bone or repair a wound, without putting you to sleep. A tight cuff on your upper arm keeps the numbing medicine in your arm and out of the rest of your body.

What will happen?

You will be awake the whole time and able to talk to us. We put a small drip in the back of each hand, then padding and a cuff on your injured arm and tighten it — this feels tight and uncomfortable, and that is normal. Your arm may feel warm or tingly and look blotchy. After about 10 minutes it will be numb. You may feel movement, but you should not feel pain — tell us straight away if you do.

Is it safe?

It has a very good safety record and serious problems are rare. Because the numbing medicine could affect your heart or brain if it escaped into your bloodstream too quickly, we watch your heart tracing and blood pressure the whole time, keep the cuff on for at least 20 minutes, and have treatment ready. That is also why you need a drip in your other arm.

How long, and do I need to fast?

Plan for around two to three hours in total, including at least an hour of watching after the cuff comes down. You do not need to fast. Afterwards you may feel dizzy or hear ringing in your ears for a short time — tell the nurse. Keep your arm in the sling and raised.

Come back to the Emergency Department straight away if you have:

▸Numbness or tingling around your mouth, or a metallic taste

▸Ringing in your ears, dizziness or blurred vision that does not settle

▸Twitching or shaking you cannot control

▸Palpitations, chest pain or breathlessness

▸Fingers that become numb, pale, blue, very painful or swollen

▸A plaster that feels too tight

Audit & Quality Capture

Record each procedure for departmental quality review and continuous improvement.

Local Storage Mode — v0.6

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 v0.7.

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.

Evidence & References

Source guidelines, where this page departs from them, and what the literature actually shows.

RCEM

Primary Guideline

RCEM

Royal College of Emergency Medicine

Best Practice Guideline: Intravenous Regional Anaesthesia for Distal Forearm Fractures (Bier's Block), revised November 2017. The source for prilocaine as first-line agent, the SBP + 100 cuff target, the 20-minute floor and the 45-minute ceiling.

Visit rcem.ac.uk →

RCH

Paediatric Reference

RCH Melbourne

Clinical Practice Guidelines

Royal Children's Hospital Bier block guideline (updated November 2020) — the source for the paediatric parameters used here: lignocaine 0.5%, SBP + 75 mmHg to a 250 mmHg maximum, and the 20–45 minute cuff window.

Visit rch.org.au →

ASRA

LAST Management

ASRA

Regional Anesthesia & Pain Medicine

LAST Checklist (2020) and Third Practice Advisory. The source for lipid emulsion dosing, reduced-dose adrenaline, amiodarone as the antiarrhythmic of choice, and the stocked-rescue-kit requirement.

Visit asra.com →

Where This Page Departs From Its Sources

Deliberate Departures — and Why

Where RCEM, RCH, ASRA and published ED guidelines conflict, the position taken here is set out with its reasoning. Each of these requires specific local endorsement rather than blanket approval.

Item	Source position	This page	Reasoning
Adrenaline in LAST	1 mg 1:1000 per ARC ALS in arrest	Reduced boluses, 1 microgram/kg or less	ASRA advises below 1 microgram/kg; standard doses worsened outcomes in animal models and impair lipid rescue. Generic ALS dosing was not written for LAST.
Sodium bicarbonate	Sodium-channel antidote, 1–2 mmol/kg repeated	Removed as an antidote	That is the tricyclic overdose regimen. It is not in the ASRA LAST algorithm, which specifies lipid, benzodiazepines, reduced-dose adrenaline and amiodarone. Retained only as a consideration for severe acidosis.
Maximum cuff time	RCEM and RCH: 45 min. Some services: 90 min	45 min; 60 with FACEM approval	Both college guidelines specify 45. Guay reports seizures after deflation at tourniquet times up to 60 minutes, so longer inflation does not guarantee safety. Ischaemia and cuff pain also increase with time.
Single vs double cuff	RCEM: double cuff, to permit rotation	Single cuff	Eliminates wrong-cuff deflation, the more likely error in a low-volume department. Trade-off accepted: no rotation for cuff pain, so procedures are time-limited. Diverges from RCEM and must be signed off knowingly.
Cycled deflation	Absent from RCEM and RCH; present in anaesthetic texts	Retained, bounded, marked ○	No randomised or cohort evidence of benefit. Low cost, plausible rationale. Labelled so it is not mistaken for an evidence-based step, and omitted where cuff time already exceeds 40 minutes.
Pre-drawn antidotes	Some protocols require antidotes drawn up before injection	Stocked and mapped, not pre-drawn	ASRA specifies a rescue kit and checklist. Pre-drawing adds wastage and labelling risk without addressing recognition, the actual rate-limiting step. Also avoids a stocking issue becoming a barrier to an appropriate block.
Refusal of second IV	Not addressed in any source guideline	Absolute contraindication	A governance judgement, not an evidence-based one. Flagged for debate — reviewers may reasonably take a different view.
Hypertension threshold	RCEM: 200 mmHg. Some services: 220 mmHg	200 mmHg	The more conservative of the two, and the college position.
Benzodiazepine	RCEM: diazepam or lorazepam	Midazolam	Standard Australian ED practice and available in ED imprest.
Relative CI handling	Some protocols escalate only at two or more	Any single relative CI requires consultant discussion	The two-CI threshold has no published basis and would allow, for instance, an epileptic patient to proceed unreviewed.

What the Literature Actually Shows

Evidence Summary

Stated openly so clinicians can distinguish genuinely evidence-based requirements from convention.

Question	Certainty	Finding
IVRA vs haematoma block for distal radius manipulation	●	RCEM recommends IVRA; haematoma block gives less analgesia and may compromise reduction. Supported by Kendall 1997 and Oakley 2023 cohort data.
Prilocaine as the preferred agent	●	Guay's systematic review: cardiac arrests and deaths reported with lignocaine and bupivacaine only; seizure threshold 4 mg/kg for prilocaine versus 1.4 mg/kg for lignocaine.
Fasting not required	◐	O'Sullivan 1996 survey; endorsed by RCEM. Observational.
Minimum 20 minutes before deflation	◐	Consistent across RCEM, RCH and anaesthetic texts, based on tissue-binding pharmacokinetics rather than trial data. A retrospective cohort of 430 patients deflated before 20 minutes exists and should be read directly.
Deflation after 20–30 minutes is safe	○	Not established. Guay reports seizures after deflation at tourniquet times up to 60 minutes. Monitoring after deflation is mandatory regardless of cuff time.
Cycled deflation reduces toxicity	○	No randomised or cohort evidence located. Pharmacokinetic rationale only. Absent from both college guidelines.
Prophylactic contralateral IV access	○	Universal in guidelines (RCEM, RCH and published ED protocols) but no comparative outcome data. Consensus safety practice.
Methaemoglobinaemia risk at 3 mg/kg prilocaine	◐	RCEM: usually seen above 16 mg/kg. Risk at protocol dose is very low. Genuine risk group is infants under 6 months.
Reduced-dose adrenaline in LAST	◐	ASRA recommendation based on animal models; no human RCT. Consistent across ASRA, APSF and AAGBI.
Lipid emulsion for LAST	●	Established standard of care; supported by animal models, case series and society guidelines.
US-guided supraclavicular block as an alternative	◐	SUPERB (Tsao 2025) — single-site Australian RCT, 78 patients, non-inferior with longer analgesia. Promising but not yet a basis for replacing IVRA.

Reference List

Royal College of Emergency Medicine. Best Practice Guideline: Intravenous Regional Anaesthesia for Distal Forearm Fractures (Bier's Block). Revised November 2017.
Royal Children's Hospital Melbourne. Clinical Practice Guideline: Bier block. Last updated November 2020.
O'Mahony N, Leech A, Armstrong J. Bier's Block Guideline, Sir Charles Gairdner Hospital Emergency Department, Western Australia. Updated 10 December 2024.
Neal JM, Neal EJ, Weinberg GL. ASRA Local Anesthetic Systemic Toxicity Checklist, 2020 version.
Neal JM, Barrington MJ, Fettiplace MR, et al. The Third ASRA Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017. Reg Anesth Pain Med 2018;43(2):113–123.
Guay J. Adverse events associated with intravenous regional anesthesia (Bier block): a systematic review of complications. J Clin Anesth 2009;21(8):585–594.
Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg 2009;108(3):837–845.
Tsao H, Tang C, Cureton A, et al. SUPraclavicular Block for Emergency Reduction of Upper Limb Injuries Versus Bier Block (SUPERB): an open-label, noninferiority randomised controlled trial. Emerg Med Australas 2025;37:e70069.
Oakley B, Busby C, Kulkarni S, et al. Manipulation of distal radius fractures: a comparison of Bier's block vs haematoma block. Ann R Coll Surg Engl 2023;105(5):434–440.
Kendall JM, Allen P, Younge P, Meek SM, McCabe SE. Haematoma block or Bier's block for Colles' fracture reduction in the accident and emergency department — which is best? J Accid Emerg Med 1997;14(6):352–356.
O'Sullivan I, Brooks S, Maryosh J. Is fasting necessary before prilocaine Bier's block? J Accid Emerg Med 1996;13(2):105–107.
Jakeman N, Kaye P, Hayward J, et al. Is lidocaine Bier's block safe? Emerg Med J 2013;30(3):214–217.
Gurich RW, Langan JW, Teasdall RJ, Tanner SL, Sanders JL. Tourniquet deflation prior to 20 minutes in upper extremity intravenous regional anesthesia. Hand (N Y) 2017.
Association of Anaesthetists of Great Britain and Ireland. Safety Guideline: Management of Severe Local Anaesthetic Toxicity.
Australian and New Zealand College of Anaesthetists — professional documents relating to regional anaesthesia and monitoring.
Australian Medicines Handbook, current edition — prilocaine, lignocaine, methylene blue, lipid emulsion, midazolam, adrenaline.
Citanest 0.5% prilocaine hydrochloride 250 mg/50 mL injection vial, ARTG 12079. Product Information, Aspen Pharmacare Australia.
LITFL — Bier's Block. FOAMed clinical reference.

About This Module

This visual operating manual synthesises clinical content from peer-reviewed sources and published emergency department guidelines. It is intended for educational use and as a cognitive aid during procedure setup — not as a substitute for local protocol, senior clinical judgement, or formal credentialing pathways.

For implementation in your department, adapt to local pharmacy formulary, anaesthetic governance, equipment availability and credentialing requirements. All drug doses, product presentations and equipment references must be independently verified against the current Australian Medicines Handbook, the product information for the stock actually held, and local imprest before use.