Tasmanian Department of Health and Human Services
Royal Hobart Hospital
Clinical Guidelines
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.
RHH EMERGENCY DEPARTMENT INTRAVENOUS REGIONAL
ANAESTHESIA: BIERS BLOCK
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Background
Objective
Contraindications
Principles of Management
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ED-1-0012
Follow-up
References
Stakeholders
Key Words
Background
Intravenous Regional Anaesthesia (Biers Block) is a procedure often undertaken in the emergency
department for children (over 10 years old) and adults with single closed forearm and lower leg
fractures or lacerations requiring manipulation or repair that can be completed within a 40-60 minutes
timeframe. It is a technique utilising the injection of rapid onset anaesthesia into a vein distal to the
injury to gain muscle relaxation and anaesthesia, while a proximal tourniquet remains in place. It can
often avoid the patient undergoing a general anaesthetic and decrease hospital length of stay.
Objective
The aim of this guideline is to promote consistent management of patients requiring Intravenous
Regional Anaesthesia (Biers Block) within the Emergency Department (ED).
Contraindications
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Uncooperative patient
Age of patient (less than 10 years )
Unstable epilepsy
Uncontrolled hypertension
Severe liver disease
Peripheral vascular disease
Lack of availability of resuscitation equipment
Procedure lasting greater than 60 mins
Allergy to anaesthetic agents
Injury at tourniquet site
Second or third degree heart block
Severe vascular disease
Sickle cell disease
Open fractures
Custodian: Emergency Department CNC
Effective Date: September 2013
Review Date: September 2017
Authorised by: Director Emergency Medicine
Document File Name: Biers Block Guideline
Page 1 of 4
Tasmanian Department of Health and Human Services
Royal Hobart Hospital
Clinical Guidelines
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.
RHH EMERGENCY DEPARTMENT INTRAVENOUS REGIONAL
ANAESTHESIA: BIERS BLOCK
ED-1-0012
Principles of Management
Requirements before starting procedure:
 Available staff including ED registrar or consultant with airway management skills and Biers
blocks experience, and a procedure doctor. A procedure nurse with Biers Block experience
must be available to monitor both the patient and the Biers Block machine/cuff
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Obtain patient consent
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Obtain patient’s weight
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Ideally the patient will have been fasting for a minimum of 4 hours
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Resuscitation equipment available: oxygen, suction, BVM, and airway adjuncts
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Oxygenation and anticonvulsants are the main treatment if accidental cuff deflation occurs, the
first signs of local anaesthetic toxicity are indicated by peri-oral tingling/numbness, followed by
altered conscious state and seizures. If toxicity occurs an Intralipid infusion is recommended
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Radiographer must be notified and be available to provide post reduction films prior to cuff
release
Technique:
 Insert two IV cannulas, one small gauge distal to the injury in the limb (usually medical officer
will insert this) undergoing the procedure, and one in the opposite limb for emergency access.
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Apply several layers of Velband around the upper arm of the affected limb to provide padding
and protection under the tourniquet.
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Record a full set of baseline vital signs and record on the Procedural Sedation Form.
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Apply tourniquet cuff to the upper arm of the affected limb—preferably with the connector
tubing facing proximally so as not to interfere with plaster application.
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Elevate the injured limb for several minutes to allow venous drainage and improve the
effectiveness of the Local block and decrease discomfort.
Custodian: Emergency Department CNC
Effective Date: September 2013
Review Date: September 2017
Authorised by: Director Emergency Medicine
Document File Name: Biers Block Guideline
Page 2 of 4
Tasmanian Department of Health and Human Services
Royal Hobart Hospital
Clinical Guidelines
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.
RHH EMERGENCY DEPARTMENT INTRAVENOUS REGIONAL
ANAESTHESIA: BIERS BLOCK
ED-1-0012

Inflate the proximal cuff before lowering the limb. Check cuffs for leakage: Inflate proximal cuff
to the desired pressure (usually 100mmHg greater than the patient’s systolic blood pressure
but less than 300mmHg). Confirm absence of pulse.
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Inject 0.5-0.7 ml/kg of 0.5% Prilocaine (generally 40mls for a 70kg adult), this will anaesthetise
the distal area allowing for the distal cuff to be inflated to the pressure determined above. The
proximal cuff can then be deflated.
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Document time of cuff inflation. Set time on the Biers Block machine. The cuff should be left
inflated for a minimum of 20mins (to allow for good tissue binding of Prilocaine and decrease
systemic toxicity), but left on no longer than one hour (to prevent limb ischaemia).
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Remove the IV cannula on the injured side and apply pressure to the site until bleeding
ceased. Do not cover with a dressing as limb will be plastered.
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Assess completeness of the block at 10mins. If anaesthesia is satisfactory then reduce and
plaster the fracture.
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Obtain lateral and AP films of limb. If satisfactory, then release the cuff (not before 20mins). If
unsuccessful then attempt further reduction and release the cuff—more than two attempts are
unlikely to improve the fracture so ongoing limb ischaemia is unwarranted.
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If the reduction is successful then observe the patient for 60 mins prior to discharge.
Follow-up
The following needs to be completed when the patient is ready for discharge:
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Fit sling and elevate limb.
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Ensure adequate analgesia to go home with.
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Discuss the signs and symptoms of neurovascular compromise.
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Follow up in fracture clinic in 7 days or by private Orthopaedic Surgeon.
Custodian: Emergency Department CNC
Effective Date: September 2013
Review Date: September 2017
Authorised by: Director Emergency Medicine
Document File Name: Biers Block Guideline
Page 3 of 4
Tasmanian Department of Health and Human Services
Royal Hobart Hospital
Clinical Guidelines
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.
RHH EMERGENCY DEPARTMENT INTRAVENOUS REGIONAL
ANAESTHESIA: BIERS BLOCK
ED-1-0012
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Give patient plaster care instruction leaflet and instructions to return to GP if signs and
symptoms of limb ischaemia occur.
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Emergency Multidisciplinary Team (EMAT) referral if patient more than 65 years old
References
1. Guay, J., 2009, Adverse events associated with intravenous regional anaesthesia (Bier block):
a systematic review of complications, Journal of Clinical Anaesthesia, 21, pp 585-594.
2. Sprot, H., Metcalfe, A., Odutola, A., Palan, J., White, S., 2012, Emergency Medical Journal,
March.
Stakeholders
Emergency Department Royal Hobart Hospital Consultants
Emergency Department Director
Emergency Department NUM
Emergency Department Royal Hobart Hospital CNC
Emergency Department Royal Hobart Hospital CNEs
Key Words
1. Intravenous regional anaesthesia
2. Rapid onset analgesia
3. Cannula
Custodian: Emergency Department CNC
Effective Date: September 2013
Review Date: September 2017
Authorised by: Director Emergency Medicine
Document File Name: Biers Block Guideline
Page 4 of 4