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Clinical Competencies

22
  • ECG Interpretation
  • Advanced Cardiac Life Support – Basic Airway Management For Operating Room Nurses
  • Introduction to History Taking Skills
  • Examination of the Abdomen
  • Examination of the Heart
  • Examination of the Pelvis
  • Examination of the Thorax and Lungs
  • Examination of the Rectum
  • Conscious Sedation and analgesia competencies
    • Introduction To Harvey Cardiopulmonary Simulator
    • Standards Of Practice
    • Patient Assessment
    • Difficult Airway
    • Drug Pharmacology
    • Introduction, Goals And Indications For Administration Of Sedation
    • Managing Complications
  • CanMEDS Framework Competencies for Medical Students
    • Collaborator
    • Communicator
    • Health Advocate
    • Leader
    • Medical Expert
    • Professional
    • Scholar

Procedural Competencies

39
  • Airway management
  • IV access
  • Local anesthesia/field block
  • Suturing of Lacerations
  • Pap Smear
  • Nasogastric tube placement
  • Venipuncture
  • Abscess incision and drainage
  • Urethral catheterization
  • Oxygen administration devices
  • Thoracentesis
  • Lumbar puncture
  • Anoscopy
  • Arterial line placement
  • Central venous catheter placement
  • Intramuscular Injection
  • Pericardiocentesis
  • Emergency Resuscitation Principles
  • Circulation Assessment & CPR
  • Rectal Examination
  • Electrocautery
  • Epidurals
  • Intraosseous Infusion
  • Ultrasound-guided Central Line Insertion
  • Simulation Debriefing
  • Wound Treatment
  • Introduction, Goals And Indications For Administration Of Sedation
  • Central Vein Catheterization Landmark Technique
  • Chest tube placement and management
  • Spontaneous vaginal delivery
  • Types of Surgical Knots
  • Tying Technique
  • Principles of Asceptic Technique
  • General Principles
  • Laparoscopic Equipment
  • Handling Laparoscopic Instruments
  • Basic Laparoscopic Techniques
  • Managing Complications
  • Tracheostomy

Nursing Competencies

85
  • Wound Management
    • Wound Prevention
    • Wound Assessment
    • Wound Treatment
  • Advanced Clinical Nursing Management (Pre Code & Code)
    • Cardiac Failure
    • Renal Failure
    • Tracheostomy Care
    • Suctioning In Respiratory Care
    • Fluid And Electrolytes
    • Basic Airway Management For Operating Room Nurses
    • Medical-Surgical Nursing Comprehensive Scenario
    • Pre Operative Assessment
    • Neurological Trauma
    • Bipap & CPAP
    • Respiratory Failure
    • Shock
    • Respiratory Assessment
    • Oxygen Therapy
  • COPD and its Management
    • Acute Exacerbations
    • End-of-Life Care
    • Definition, Prevalence, Signs & Symptoms
    • Risk Factors And Pathophysiology
    • Diagnosis And Severity
    • Management Of Stable COPD
    • Patient Self-Management Education
  • Procedural Sedation education for registered nurses
    • Introduction To Laerdal SimMan
    • Standards Of Practice
    • Patient Assessment
    • Difficult Airway
    • Drug Pharmacology
    • ECG Interpretation
    • Introduction, Goals And Indications For Administration Of Sedation
    • Managing Complications
  • Introduction to Perioperative Nursing
    • Introduction To The Perioperative Nursing Program
    • Role Of The Perioperative Nurse
    • Preoperative Care
    • Intraoperative Care – Part 1
    • Intraoperative Care – Part 2
    • Full Time Clinical Component
    • Perioperative Anatomy & Medical Terminology
    • General Surgery
    • Perioperative Safety
  • Physical Assessment
    • Physical Examination Of The Airway
    • How To Take Blood Pressure Reading
    • Acute Bronchospasm
    • Acute Respiratory Failure
    • Cardiac
    • Pulmonary Embolism
    • Taking A Temperature
  • Procedural Sedation and Analgesia Education
    • Standards Of Practice
    • Patient Assessment
    • Difficult Airway
    • Drug Pharmacology
    • ECG Interpretation
    • Introduction, Goals And Indications For Administration Of Sedation
    • Managing Complications
  • Safe Blood Transfusion
    • Safe Blood Transfusion I
    • Safe Blood Transfusion II
  • Community Home Infusion
    • Teaching Home IV Self-Administration
    • Teaching Community Intravenous: Gravity
  • Collaborative Framework
    • Respiratory Assessment
    • Tracheostomy Care
    • Oxygen Therapy
    • Suctioning In Respiratory Care
  • Fundamental Perioperative Skills for LPN
    • Introduction To The Perioperative Skills for LPN
    • Role Of The LPN Perioperative Nurse
    • LPN Perioperative Care
    • LPN Perioperative Safety
    • LPN Intraoperative Care
  • Pain Management
    • Classification & Physiology Of Pain
    • Pain Assessment
    • Non-pharmacological Approaches For Pain Management
  • Rheumatoid Arthritis Hand
    • Ulnar Drift Deformity In Rheumatoid Arthritis
    • Boutonniere Deformity In Rheumatoid Arthritis
  • Total Joint Arthroplasty Outcome Measures
    • Thirty Second Chair Stand Test (30 Sec-CST)
    • Stair Climb Test (SCT)
    • Ten Metre Walk Test
    • Timed Up & Go (TUG) Test
    • Functional Reach Test (FRT)
    • Single Leg Stance (SLS) Test
    • Six Minute Walk Test (6MWT)
    • Visual Analogue Scale (VAS): Pain
    • Numeric Pain Rating Scale (NPRS)
    • Hip Disability And Osteoarthritis Outcome Score (HOOS)
    • Knee Injury And Osteoarthritis Outcome Score (KOOS)
    • Lower Extremity Functional Scale (LEFS)

Midwifery Competencies

34
  • Midwifery Emergency Skills Program
    • Post Partum Haemorrhage
    • Shoulder Dystocia
    • Hypertensive Disorders Of Pregnancy
    • Contraception
    • Approach To Abortion
    • Antenatal Fetal Assessment
    • Postpartum Hemorrhage
    • Caring For Sexual Assault Survivors
    • Antepartum Bleeding
    • Fetal Well Being
    • Breech
    • Twins
    • Anaphylaxis
    • Cord Prolapse
    • Communication
    • RBC Alloimmunization
    • Upper Genital Tract Infection
    • Vulvovaginitis
    • Prenatal Screening And Diagnosis
    • Intrauterine Growth Restriction
    • Medical And Surgical Complications Of Pregnancy
    • Multifetal Pregnancy
    • Postpartum Care
    • Introduction And Preparation For The Physical Examination Of Female Genitalia
    • Management Of The Infertile Couple
    • Speculum Examination
    • Performing A Pap Smear
    • Evaluation Of A Patient With A Pelvic Organ Prolapse
    • Bimanual Examination
    • Pelvirectal Examination
    • Pregnancy Hypertension
    • The Perimenopause
    • Inspection And Palpation Of External Genitalia
  • Perinatal Health
    • SOGC Guidelines: Diagnosis, Evaluation And Management Of The Hypertensive Disorders Of Pregnancy

Physiotherapy Competencies

13
  • Clinical Competence Based Simulated Physiotherapy Learning
    • Intermittent Positive Pressure Breathing/BIRD
    • Manual Techniques: Assisted Cough
    • Pneumonia In Motor Neurone Disease
    • Aspiration Pneumonia In Trauma
    • Clinical Competence Skill Set- SCI Respiratory Assessment
    • Respiratory Anatomy And Physiology
    • Basic Oxygen Therapy
    • Basic Respiratory Assessment
    • Suctioning
    • Manual Techniques: Vibrations
    • Manual Techniques: Percussion
    • Manual Hyper-Inflation (MHI)
    • Clinical Competence Skill Set – Assisted Cough

Interprofessional Skills

33
  • Home Care
    • Teaching Home Tracheostomy Care
    • Teaching Home IV Self-Administration
  • Goals of Care & Advance Care Planning
    • Goals Of Care & Advance Care Planning
  • Sterilization and Disinfection
    • Infection Prevention Principles In MDRD
    • Medical Device Reprocessing – An Introduction
    • Infection Prevention
    • Disinfection
    • Decontamination Process
    • Sterilization 1
    • Sterilization 2
    • Sterilization IUSS (Flash)
    • Sterilization Table Top Steam
    • Sterile Storage And Distribution
  • Communication Skills in ACLS & ATLS
    • Introduction To Human Factors
    • The Nature Of Human Error
    • Inter-Professional Communication Skills During Implementation Of ACLS And ATLS Simulation Session
    • Introduction To METIMan
  • Communication Skills in a Simulation Session
    • Practicing Resuscitation And Communication Skills, In An Inter-Professional Simulation Session
    • Communication
    • Team Management
  • Mobile Medical Unit
    • VANOC 2010 Medical Services
    • Introduction To The Mobile Medical Unit – History And Planning-Dr. jack Taunton
    • Summary Of Whistler Polyclinic And Mobile Medical Unit- Dr Ross Brown
    • Mobile Medical Unit Orientation To Physical Lay Out And Patient Flow (Emergency, Critical Care/Pre/Post Operative/Operating Room)
    • Olympic/Paralympic (2010), MMU Blood Education Overview- Dr. Kate Chipperfield, MD
    • Transfusion Medicine Services
    • Trauma Evaluation And Management (TEAM)
    • Abdomen-Stab Wound Case
  • Medical Device Reprocessing
    • Introduction To Reprocessing
    • Decontamination Process
    • Disinfection
    • Infection Prevention
    • Sterilization

Introduction to Simulation

38
  • Introduction to Simulators and simulation Technology
    • Patient Simulation Sessions
    • Introduction To Laerdal SimMan 3G
    • Introduction To METI SurgicalSim
    • Introduction To Laerdal SimMan Essential
    • Introduction To METI Baby Simulator (BabySim)
    • Introduction To METI Emergency Care Simulator (ECS)
    • Introduction To METI Human Patient Simulator (HPS)
    • Introduction To METI Pediatric Simulator (PediaSim)
    • Introduction To METI Pelvic ExamSim
    • Introduction To Simbionix GI Mentor II
    • Introduction To Simbionix PERC Mentor
    • Introduction To Simbionix URO Mentor
    • Introduction To Surgical Techniques Work Benches
    • Introduction To VIST
    • Introduction To Harvey Cardiopulmonary Simulator
    • Introduction To Syndaver Surgical Patient
    • Introduction To Laerdal SimBaby
    • Introduction To Laerdal Sim Man 3G
    • Introduction To Laerdal SimMan
    • Introduction To METIMan
  • Fellowship Lectures
    • Stress and Human Performance by Eric David
    • Workload Management by Eric David
    • Communication by Eric David
    • Team Management by Eric David
    • Theoretical Basis of Simulation in Health Education by Dr. Qayumi
    • Developing a Sim Centre by Dr Qayumi
    • Curriculum Development by Dr. Qayumi
    • Introduction to Human Factors by Eric David
    • The Nature of Human Error by Eric David
    • Situational Awareness – The Cornerstone of Error Prevention by Eric David
    • Fatigue and Human Performance by Eric David
    • Advancements in Simulation Debriefing by Dr. Adam Cheng
  • Scientific Method and Applied Statistics
    • Introduction To Scientific Method
    • Scientific Methods EPA 8 Lecture 1
    • Scientific Methods EPA 8 Lecture 2
    • Scientific Methods EPA 8 Lecture 3
    • Scientific Methods EPA 8 Lecture 4
    • Applied Statistical Tutorial

Surgical Competencies

7
  • Basic Surgical Techniques Competencies
    • Ch 1 – Introduction to Basic Surgical Instruments
    • Ch 2 – Handling of Surgical Instruments
    • Ch 3 – Knot Tying Techniques
    • Ch 5 – Aseptic Techniques And Operating Room Conduct
    • Ch 6 – Basic Surgical Procedures
    • Ch 4 – Wound Management Techniques
    • Ch 7 – Laparoscopic Surgical Techniques

Casting and Splinting

9
  • Cast Application by Cyberpatient Team
  • A step-by-step guide for casting and splinting by Dr Jeff Nash
    • 1 – Orthopedics Immobilization Techniques- An Introduction
    • 2 – Orthopedics Immobilization Techniques- Volar Wrist Splint
    • 3 – Orthopedics Immobilization Techniques- Long Arm Cast and Thumb Spica
    • 4 – Orthopedics Immobilization Techniques- PosteriorArm Splint(Black Slab)
    • 5 – Orthopedics Immobilization Techniques- Ulnar Gutter Splint
    • 6- Orthopedics Immobilization Techniques- Short Leg Cast
    • 7- Orthopedics Immobilization Techniques- Cylinder (Stove) Leg Cast
    • 8 – Orthopedics Immobilization Techniques- Posterior Short Leg Splint (Black Slab)

CyberPatient Experts Series

75
  • Approach to Imaging and Understanding of Different Imaging Modalities - Dr. Savvas Nicolaou
    • Approach to chest X-ray imaging and acute chest pain
    • Approach to the interpretation of the abdominal radiograph and approach to imaging of the acute abdomen.
    • Approach to brain imaging
  • Diagnostic and Procedural Imaging
    • Radiology
      • Radiology Of The Spine
      • RADIOLOGY IN PMP
      • MSK Imaging
      • Abdominal Imaging Anatomy
      • Metabolic Bone Disease Imaging
      • Radiology Of The C Spine
      • Overview – Thoracic Imaging
      • Bone Tumor Radiology
      • Practical Emergency Radiology
      • MRI Of The Knee
      • Radiological Modalities
      • Basic Approaches To Chest Radiology
      • Gout, Arthritis & Fractures
      • Approaches To Chest XRAY In Heart Disease
      • Introduction To Neuroimaging
      • Thoracic Imaging – Radiological Anatomy Of The Chest
      • Anatomy Of The Pelvis And Skull
      • ACR Appropriateness Criteria
    • Pulmonary Radiology
      • Respiratory
    • Ultrasound
      • Musculoskeletal Radiology
      • ACR TIRADS
    • Ultrasound Guided Nerve Block PEM Course
      • Bier Block Course
      • Adverse Reactions & Complications Of Peripheral Nerve Blocks
      • Physics Of Ultrasound
    • Ultrasound Guided Regional Anesthesia
      • Ultrasound Guided Blockade Of The Ilioinguinal And Iliohypogastrics Nerves
      • Physics Of Ultrasound
    • Ultrasound-Guided Emergency Medicine Procedures, Advanced Course (UGEMP-Advanced)
      • Ultrasound Guided Abscess Diagnosis And Drainage
      • Ultrasound Guided Arthrocentesis
      • Ultrasound-Guided Lumbar Puncture
      • Ultrasound Guided Paracentesis
      • Ultrasound Guided Foreign Body Identification And Removal
  • Learning in Healthcare Education Series - Dr. Karim Qayumi
    • Curriculum Development
    • Gamification in Education
    • Fundamental Theories Behind Education
    • Exploring Competency-based Education
    • Post-Series Q+A
  • Laboratory Medicine
    • Thyroid Laboratory Testing Lectures- Dr. Sophia L. Wang, MD
    • Adrenal Hypertension Lectures- Dr.Daniel Holmes, MD
    • Scientific Basis Of Lipid Disorders Lectures- Dr. Daniel Holmes, MD
    • Immunoglobulins Lectures- Dr. William E. Schreiber, MD
    • Autoantibody Testing In SARDS Lectures- Dr. Micheal C. Nimmo, MD
    • Complete Blood Count (CBC) Interpretations Lectures-Dr. Tyler Smith MD
    • Introduction To Coagulation-Dr. Tyler Smith MD
    • Transfusion Medicine Basics-Dr. Kate Chipperfield MD
    • Transport For Microbiology Labs-Michael Payne
    • Introduction To Mycology- Michael Payne
    • Laboratory Diagnosis Of Viral Infections- Dr. Christopher Lowe, MD, FRCPC
    • Evaluation Of Acid Based Status lectures – Dr. William E. Schreiber, MD
    • Disturbances In Plasma Sodium Lectures- Dr. Daniel T. Holmes, MD
    • Lab Testing In Diabetes Lectures- Dr. Sophia L. Wang, MD
  • Pharmacology and Therapeutics
    • Gastrointestinal Pharmacology Lectures- Dr. Andrew Horne, MD
    • Endocrine Pharmacology- Dr. David Miller, MD
    • Anticancer Pharmacology- Dr. Jennifer Shabbits, MD
    • Pharmacology Of Antimicrobial Agents- Dr. David Godin
    • Pharmacology Of Antiepileptics- Dr. Andrew Horne
    • Quantitative Pharmacokinetics Lectures- Dr. David Godin, MD
    • Pharmacology Of The Autonomic Nervous Systems- Lectures Dr. Micheal Walker, MD
    • Cardiac Pharmacology Lectures- Dr.Michael Walker, MD
    • Diuretics Lectures- Dr. David Godin, MD
    • Pharmacology Of Local Anaesthetics Lectures- Dr. David Godin, M
    • Pharmacology Of Inhaled Anaesthetics Lecture- Dr. Peter T. Choi, MD
    • Pharmacology Of Antidepressants- Dr. Dean Elb
    • Pharmacology And Anxiety- Dr. R. Randhawa MD
    • Pharmacology Of Antipsychotics-Dr. Ric M. Procyshyn
    • Variability In Response To Drugs-Dr. David Godin
    • Fundamental Concepts Lectures- Dr. David Godin, MD
  • Surgical and Medical Ethics Series - Dr. Alberto Ferreres
    • Medical Ethics and Bioethics 101
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    • Surgical Ethics: Principles and Practice
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Bier Block Course

12 min read

Description #

This unit will review the potential adverse reactions of the Bier block with a brief discussion of management and prevention.

Learning Objectives #

1) To understand and be able to apply the technique of a Bier block for fracture reduction

2) To understand the management of potential complications of Bier blocks including drug and pneumatic cuff related complications

3) To be able to clearly communicate the risks and benefits of the Bier block procedure to patients and their families

Introduction: #

Fractures, and in particular distal radial and ulnar fractures, are among the most common injuries presenting to the Pediatric Emergency Department (PED) [1]. These fractures can usually be managed by closed reduction in the PED [2]. Pain from reduction of upper-extremity fractures is generally mediated by the use of procedural sedation using a variety of intravenous and intramuscular medications [3]. Alternatively, the pain from reduction can be controlled by regional intravenous anesthesia (Bier block). Currently in our tertiary care PED, most fractures are reduced using procedural sedation with intravenous (IV) Ketamine. 

PED procedural sedation protocol requires that an emergency physician administer medications and be present throughout the procedure in case of airway or other complications. While procedural sedation is an excellent way to manage fractures, it requires considerable physician, nursing and other staff resources, and may involve a long recovery period. For older children and adolescents, there is a higher rate of psychotomimetic reactions from Ketamine, and a higher incidence of adverse airway events and nausea/vomiting [3,4]. These increased side effects make this protocol less desirable for older patients. Having the ability to avoid Ketamine in certain patients while still providing adequate pain control would be an excellent option for fracture reduction management. 

The Bier block is a proven and effective alternative means of controlling pain from reduction, without the negative side effects of systemic medications or the demands on departmental resources. The technique was developed in the early 1900s and has come in and out of popularity throughout the last century [5]. The Bier block consists of inserting an intravenous catheter into the fractured arm, elevating the arm for several minutes and placing a pneumatic cuff on the upper arm. Once the cuff is inflated, a solution of Lidocaine is injected into the arm and within approximately 15 minutes, there is good anesthesia. The fracture is reduced and casted, and then the cuff is deflated slowly to prevent a large Lidocaine bolus entering the circulatory system [5].

Advantages of Bier Blocks over Procedural Sedation #

The advantages of Bier blocks over procedural sedation can be summarized in the following acronym:

What is a Bier Block? #

The Bier block is a technique of limb anesthesia which does not require systemic medication. An intravenous catheter is placed in the patient’s broken limb, which is then elevated for two minutes to allow passive blood drainage. Following elevation, a blood pressure cuff is placed proximal to the fracture, with soft-roll underneath for comfort, and inflated to pressures well above systolic to occlude blood flow to the limb. The picture below shows the Bier block set-up.

Page 1 #

Once the limb blood flow has been occluded, Lidocaine is injected into the arm (note the normal mottling of the skin in the picture below). After Lidocaine injection, the IV is then removed prior to fracture reduction. Within 10 or 15 minutes, the limb is anesthetized allowing closed reduction of the fracture.

#

Page 2 #

Once the fracture is reduced and satisfactory alignment is confirmed by imaging, the limb is casted.

#

The cuff is deflated slowly using a deflation then re-inflation technique over several minutes. The length of time needed to reduce the fracture and cast the arm allows the Lidocaine to be tissue bound so that no bolus is delivered to the systemic circulation. For greater detail, please see the linked Bier block protocol for the Montreal Children’s Hospital.

https://cyberpatient-assets.s3-us-west-2.amazonaws.com/production/assets/EducationalResources/Diagnostic+and+procedural+imaging+/Medical+imaging/thoracic+radiology/Interprofessional_Protocol_Paediatric_Emergency_Bier_Block_Approved_May_14_2012.pdf

 Absolute contraindications include:  

  • Allergy to local anesthetics (rare)
  • Pathologic hypertention
  • Seizure disorders
  • Blood dyscrasias (ex: Hemophelia, sickle cell)
  • Crush injury or compromised circulation (compartment syndrome, Reynaud’s disease or peripheral vascular disease)
  • Complex medical condition
  • Open fracture
  • Infection of the limb
  • Methemoglobinemia
  • Morbid obesity
  • Procedure required in both arms
  • Patients not eligible for procedural sedation
  • Parent/Patient refusal

Relative contraindications include:

  • Age < 6 years
  • Patient anxiety
  • Morbid obesity
  • Inability to tolerate cuff inflation
  • Anticipated procedure time > 1 hr

Complications of Bier Blocks can be divided into two categories: #

In a series of over 1800 patients receiving Bier blocks at the Whistler Health Care Centre, there were no significant morbidity or mortality [5]. In addition, a recently published two year retrospective review comparing pediatric reductions done with Bier blocks to procedural sedation at the Atlanta Scottish Rite Hospital found no major complications in the 600 patients reduced using Bier blocks for analgesia of the limb. Although the Bier block has been shown to be safe in the literature and in practice, awareness of potential complications allows providers to be prepared for the worst.

Drug Related Complications: #

CNS Toxicity:

Local anesthetics are lipophilic, weak bases that easily cross the blood-brain barrier. Animal models have shown that hypercapnia or acidosis increases the risk of CNS toxicity from local anesthetics [6]. In general, because the CNS is more susceptible than the CVS to the actions of local anesthetics, CNS symptoms normally precede CVS symptoms.

Notes:

1) The maximum dose for Lidocaine is 3 mg/kg without Epinephrine. 

2) Aminoamides (such as Lidocaine) are metabolized primarily by hepatic cytochrome P450-linked enzymes.

3) Systemic toxicity (neurologic and cardiac) is increased in patients with right-left cardiac shunts.

Progressive Symptoms and Signs of CNS Toxicity: #

Management: Routine CNS depression and seizure management are recommended, however, in the management of lidocaine induced seizures, should it become necessary start a second line agent after benzodiazepines, barbiturates ( phenobarbital) are recommended rather than phenytoin ( Dilantin), as phenytoin shares pharmacologic properties ( i.e., sodium channel blockade) with lidocaine and may potentiate toxicity.

Clickhere:https://cyberpatient-assets.s3-us-west 2.amazonaws.com/production/assets/EducationalResources/Diagnostic+and+procedural+imaging+/Medical+imaging/thoracic+radiology/status_epilepticus_chart_final_version.pdf

Direct Cardiac Effects of Local Anesthetics: #

Local anesthetics primarily act on sodium channels by decreasing the rate of depolarization [7]. Extremely high concentrations of local anesthetics depress pacemaker activity in the sinus node, resulting in sinus bradycardia and sinus arrest.

All local anesthetics exert a dose-dependent negative inotropic action on cardiac muscle proportionate to their potency. In addition, Bupivacaine binds irreversibly to cardiac muscle. Thus, bupivacaine is a more potent cardiodepressant than Lidocaine [8].

Ventricular arrhythmias may occur after rapid intravenous administration of a large dose of Bupivacaine but far less frequently with Lidocaine [9]. For the above reasons, Lidocaine is the local anesthetic of choice for Bier blocks.

Direct Peripheral Vascular Effects: #

At low concentrations, Lidocaine and Bupivacaine produce vasoconstriction, whereas high concentrations cause vasodilation. Local anesthetics also increase pulmonary vascular resistance, but this response may reflect circulatory or respiratory depression from the drugs’ effects on the CNS.

Management #

Studies suggest that a bolus of 20% Intralipid followed by infusion until the patient is stable may improve outcomes in cases where Bupivicaine was accidentally used instead of Lidocaine, or where severe toxicity persist from any local anesthetic. It is thought that the IV fat emulsion works by extracting the lipid soluble local anesthetic molecules from the aqueous plasma phase [10]. Thus, in addition to routine management of cardiac arrest, one should consider Intralipids if symptoms of local anesthetic toxicity persist. Please see MCH treatment algorithm below for more details:

MCH Bupivacaine Toxicity Algorithm:

https://cyberpatient-assets.s3-us-west-2.amazonaws.com/production/assets/EducationalResources/Diagnostic+and+procedural+imaging+/Medical+imaging/thoracic+radiology/BupToxicity_Algorithm.pdf

Summary of Signs and Symptoms of Lidocaine Toxicity #

The symptoms (italics) and signs of Lidocaine toxicity can be easily remembered using the following mnemonic:

  #

#

Allergies: #

Allergic reactions to Lidocaine are very rare.  

Prospective studies indicate that very few suspected reactions are confirmed to be allergic reactions [11]. Although the aminoamide anesthetics, such as Lidocaine, appear to be relatively free of allergic-type reactions, solutions of these drugs may have come in contact with latex or contain a preservative, methylparaben, which may cause anaphylaxis [12]. Routine anaphylaxis treatment would be appropriate in such cases. Click here to see MCH Anaphylaxis Guideline (https://cyberpatient-assets.s3-us-west-2.amazonaws.com/production/assets/EducationalResources/Diagnostic+and+procedural+imaging+/Medical+imaging/thoracic+radiology/ACUTE_TREATMENT_OF_ANAPHYLAXIS.pdf)

Note: Local anesthetics are available in a preservative-free preparation.

Equipment Related Complications #

The Bier block machine, known as the Automatic Tourniquet System 3000, needs to be checked prior to every usage for leaks in the bladders of the cuff or tubing. Usually, cuffs with two bladders are used so that there is a back-up cuff. The second cuff can also act as an alternative when the cuff pressure becomes uncomfortable for the patient (the second cuff can be inflated then the inital cuff deflated). 

Mohr and collegaues, in their patient series of 1816 Bier block procedures had only 3 cases of improper cuff inflation (a rate of 0.17%) none of which resulted in mortality or morbidity [5]. Given that the patient is conscious throughout the procedure, they are able to report lack of pressure or changes in the cuff feeling reducing the possiblity of significant morbidity or mortality.

Prevention and Precautions: #

The following recommendations are suggested to decrease the risk of adverse reactions with Bier blocks:

  • Set machine pressure above baseline BP

Remember to always set the machine’s pressure above the patient’s baseline BP. We will cover how to calculate and adjust proper limb occlusion pressure and return to profusion pressure on the day of the course.

  • Fully inflate cuff and test cuff pressure prior to injection

Prior to injection, test the cuff with a quick squeeze to ensure that it is inflated and tight, and to ensure that pressure is well maintained. 

  • Inject IV Lidocaine slowly over 1-2 minutes

Observe for normal blanching or mottling of the skin, and for signs of toxicity (remember the LIDOCAINE mnemonic).

  • Resuscitation Equipment and Medications:

The potential for respiratory depression, seizures and even cardiac arrest necessiates full monitoring. Resuscitation equipment and medications should be immediately available in the emergency cart. 

Note: Attention to the ECG may be the difference between a toxic and lethal dose.

Figure 2: Profound ST elevation and increased T-wave amplitude 15 seconds after an intravascular injection with Bupivacaine with Epinephrine followed by decreased heart rate and rapid resolution of ST-T changes after stopping the injection [13].

A few more tips: #

  • Choose your local anesthetic solution wisely

Plain Lidocaine is the anesthetic of choice for Bier blocks and will be the only one available in our department for this procedure.

  • Repeating blocks after a failed reduction (this may be an indication for the OR)

Repeated blocks can be done within two hours, at the physician’s discretion. However, failed reduction may be an indication for the O.R. not for a trial of procedural sedation. 

  • Post-block care

Two sets of vital signs need to be done after cuff release. The patient is fit for discharge after 20 minutes post-cuff release, and if needed may go for confirmatory x-rays after the two sets of vital signs are taken. Ideally, the patient should not need to go to the observation room post-procedure.

Summary #

The Bier block is a relatively quick method of intravenous anesthesia for fracture reduction. It is low risk and does not require fasting or sedation.

Using the Bier block avoids the risks of systemic drugs used for procedural sedation.

Being knowledgeable of the potential adverse reactions to local anesthetics will better prepare you should one occur, and help you to safely perform this technique on your patients.

Thank you for taking the time to do the online component of the course.

References: #

[1] Migita RT, Klein EJ, Garrison MM. Sedation and analgesia for pediatric fracture reduction in the emergency department.  Arch Pediatr Adolsec Med. 2006;160:46-51.

[2] Blasier RD, White R. Intravenous regional anesthesia for management of children’s extremity fractures in the emergency department. Pediatric Emergency Care. 1996;12(6):404-6.

[3] Kennedy RM, Luhmann JD, Luhmann SJ. Emergency department management of pain and anxiety related to orthopedic fracture care: A guide to analgesic techniques and procedural sedation in children.  Pediatr Drugs. 2004;6(11):11-31.

[4] Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, et al., Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children.  Ann Emerg Med. 2009;54(2):158-68.

[5] Mohr B. Safety and effectiveness of intravenous regional anesthesia (Bier block) for outpatient management of forearm trauma.  Can J Emerg Med. 2006;8(4):247-50.

[6] Englesson S: The influence of acid-base changes on central nervous system toxicity of local anaesthetic agents. I. An experimental study in cats. Acta Anaesthesiol Scand 1974; 18:79-87.

[7] Wagman IH, De Jong RH, Prince DA: Effects of lidocaine on the central nervous system. Anesthesiology 1967; 28:155-172.

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[15] Google images

[16] Dr. Weinberg, Bupivacaine Toxicity in a Rat Rescued by Lipid emulsion video clip

Adverse Reactions & Complications Of Peripheral Nerve Blocks
Table of Contents
  • Description
  • Learning Objectives
  • Introduction:
  • Advantages of Bier Blocks over Procedural Sedation
  • What is a Bier Block?
  • Page 1
  • Page 2
  • Complications of Bier Blocks can be divided into two categories:
  • Drug Related Complications:
  • Progressive Symptoms and Signs of CNS Toxicity:
  • Direct Cardiac Effects of Local Anesthetics:
  • Direct Peripheral Vascular Effects:
  • Management
  • Summary of Signs and Symptoms of Lidocaine Toxicity
  •  
  • Allergies:
  • Equipment Related Complications
  • Prevention and Precautions:
  • A few more tips:
  • Summary
  • References:
Educational Resources
  • Dashboard

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