Regional Blocks

Question 1

Biers Block - Indications , C/I, Complications

Answer 1

Indication: Close redux forearm #

C/I: Compartment syndrome, uncooperative patient,
- Sickle cell disease
- SBP >220,
-Compromised circulation to limb
- No IV access on arm (lymphoedema, scleroderma)

Complications: LA toxicity
- Compartment syndrome
- Neuropraxia
- Methemoglobinaemia (prilocaine)

Question 2

Biers Block Steps

Answer 2

1. Preparation: monitoring - cardiac, IVF, Airway trolley, Antidode, Personnel
2. 2x IVC distal to #
3. Inflate cuff to 100mmHg above SBP, set timer 25mins
4. Infiltrate Prilocaine 3mg/kg
5. Wait 5-10mins, close reduction
6. Deflate, observe at least 1 hr & DC post X Ray

Question 3

Steps to improve safety nerve blocks in ED.

Answer 3

• Limit LA agents options incl strength
• Credentialing process
• Education for staff
• More senior staffing on the floor
• Double checking doses for Paeds

Question 4

Hematoma Block
- Indication
- C/I
- Complications

Answer 4

I: close reduction of # forearm
C/I : open #, overlying skin infection, allergy
Complications: Infection, NV injury, Failure, Compartment Syndrome

Question 5

Hematoma Block Steps

Answer 5

Consent & R/V X ray
Palpate # for bony step
Insert needle (23G) & aspirate looking for blood to confirm.
Infiltrate 10-15mls Lignocaine 1%.
Wait 10mins for effect.

Question 6

Posterior Tibial Nerve Block
- Sole of foot

Answer 6

• Prep and clean skin.
• Palpate posterior tibial artery posterior to medial malleolus & anterior to achilles tendon.
• Superior 0.5-1cm from posterior tibial artery.
• US between medial malleolus & achilles tendon.
• Identify tibial nv on US (next to tibial art + vein).
• Insert needle & inject 2-4mls.

Question 7

Femoral nerve block

Answer 7

-Consent
- Sterile technique - US probe cover, Chlorhex on skin.
- Prepare LA & dilute 20-30mls with saline for volume block - 3mg/kg Ropivacaine, 2mg/kg Bupivacaine.
- Identify anatomy on US
- Infiltrate with In plane/out of plane technique with nerve block needle & ensure needle tip is visualised at all times.
- Inject & aspirate every 3-5mls & aim donut of LA around nerve.
- Monitor for signs of possible LA toxicity.

Question 8

Femoral NV block
I, C , C

Answer 8

• femoral shaft #
  FIB - blocks femoral/obturator/ lat cutaneous nv
  Complications - failure, adverse drug rxn, LA toxicity