Bier Block | The KP EM Residency

Bier Block


 A 14 year old male comes into the ED with a badly displaced and angulated radius and ulna fracture. There is faint capillary refill and the patient is in severe pain. You want to reduce the fracture immediately. The patient is vomiting as a result of dilaudid and the carne asada burrito, chips, cookies and birthday cake he has just finished eating making you reluctant to use procedural sedation. A hematoma block fails to provide adequate anesthesia and you are unable to position the arm to attempt an ultrasound guided nerve block. What can you do?:

Intravenous Regional Anesthesia (aka: A Bier Block)
Use: Fractures/Dislocations/Complex Wounds of the mid-distal upper (or lower) extremity.
Procedures that take <60minutes.


  • An IV or butterfly is placed in the hand of the affected limb. Use a small gauge needle.
  • The upper arm is wrapped with cast felt padding (optional) before the application of a manual BP cuff.
  • Ensure no cuff leak prior to performing.
  • A 0.5% solution of lidocaine is used at a dose of 1.5-3mg/kg- drawn into a 60cc syringe.
    • For a 70kg adult this comes out to 20-40cc of 0.5% lidocaine (WITHOUT EPI).
    • If 0.5% is not available, use 10-20cc of 1% lidocaine diluted with equal parts saline.
  • Elevate the arm for 1-2 minutes and ‘strip’ the veins of blood to attempt to exsanguinate the limb.
    • In the OR, a tight rubber bandage (esmarch bandage) is circumferentially applied proximal to distally to achieve this- difficult to do in an acutely injured limb and not needed.
  • Inflate the BP cuff to 100mHg over the patients SBP while the arm is elevated.
  • Inject the entire anesthetic solution by slow IVP into the angiocath/butterfly with the cuff inflated.
  • Patient will begin to complain of tingling and a warm or cold feeling and the skin will become mottled.
  • Can remove the IV/butterfly at this point.
  • Wait 5-10 minutes. The limb should now be entirely anesthetic distal to the BP cuff.
  • Ensure that the cuff stays >100 above systolic. May need to clamp cuff or re-inflate on occasion to maintain tourniquet effect.
  • The cuff is deflated using a “deflation/re-inflation” technique to reduce the risk of a significant IV bolus of lidocaine reaching the central circulation, whereby for 3 cycles the cuff is deflated for 5 seconds and then re-inflated for 1 minute. (Dr. Reeve says this is not needed). Some authors recommend maintaining tourniquet for a minimum of 30 minutes to prevent significant bolus of lidocaine into central circulation.

Recall toxic dose of lidocaine without epi is 5mg/kg (70kg adult= 350mg (35ml) (Lidocaine with epi=7mg/kg)

pdf iconBier Block.pdf

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