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PED-EM-L  October 2013

PED-EM-L October 2013

Subject:

Re: PED-EM-L Digest - 8 Oct 2013 to 9 Oct 2013 (#2013-219)

From:

"Cordle, Randy" <[log in to unmask]>

Reply-To:

Cordle, Randy

Date:

Thu, 10 Oct 2013 13:49:06 +0000

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (922 lines)

Yes it plays a role however it is not as good sedation with ketamine or propofol because the child still awake still has anxiety still has fear and sometimes responds to this when they see their arm bent backwards for example. It does work in the vast majority cases of properly done even with the many Bier block form.  Typically they can be discharged after the effect has worn off so you can do a nerve vascular exam. With the many beer block this is not long after you left the cost down to remember you need to keep the cuff up until it's protein-bound.  Assuring the child has sensation back so you can assess the cast if placed is one of the keys. If you send them home before this you could be creating a disaster for yourself later. I developed a protocol for this use in the emergency department years ago and did use it for years however now I probably use it on average one time a year. Sedation with ketamine or propofol is just that much better and easier. I do use it however for lacerations but even in this case I prefer to use ultrasound guided nerve blocks over using bier block in most cases.
Randy Cordle
Sent from my iPhone

> On Oct 10, 2013, at 12:00 AM, "PED-EM-L automatic digest system" <[log in to unmask]> wrote:
>
> There are 14 messages totaling 1171 lines in this issue.
>
> Topics of the day:
>
>  1. Bier Block (12)
>  2. Bedside Ultrasound
>  3. University of Chicago Job Posting
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> ----------------------------------------------------------------------
>
> Date:    Wed, 9 Oct 2013 00:29:27 -0400
> From:    Musab Yahia <[log in to unmask]>
> Subject: Bier Block
>
> Hi Everyone!
>
> I wanted to get input from anyone who's had experience using Bier blocks for fracture reductions. I've had several cases in the past couple of weeks where kids sustained a distal upper extremity fracture (which require reduction) and ate something shortly prior to ED arrival. Moderate sedation isnt an option and getting into the OR within a reasonable time frame isn't possible.
>
> 1. Is the Bier block practical for use in the ED? When used, how long after do you monitor the patient for?
> 2. Would you prefer it in fracture reductions versus if moderate sedation was an option?
> 3. Other than the potential of lidocaine causing an arrhythmia if improperly done, what complications have you seen from the Bier block?
>
> Any input is appreciated.
>
> Musab Al-Yahia, MD
> Gulf Coast Medical Center Emergency Room
> Panama City, Florida
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> ------------------------------
>
> Date:    Tue, 8 Oct 2013 21:47:14 -0400
> From:    Kamal Chavda <[log in to unmask]>
> Subject: Bedside Ultrasound
>
> Hi,
>
> Can anyone tell me their experience with pediatric ER bedside ultrasound? (other than routine IV access, soft tissue studies etc.)
>
> Thoughts / comments.
>
> Kamal Chavda
> [log in to unmask]
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> ------------------------------
>
> Date:    Wed, 9 Oct 2013 22:22:03 +1100
> From:    Mike South <[log in to unmask]>
> Subject: Re: Bier Block
>
> This is our Clinical Practice Guideline for Biers Block
>
> http://www.rch.org.au/clinicalguide/guideline_index/Biers_Block/
>
> Cheers
>
> Mike
> Prof Mike South
> Paediatrician & Intensivist,
> Chief Medical Information Officer
> Professor, University of Melbourne
> Director, Department of General Medicine
> Honorary Fellow, Murdoch Childrens Research Institute
>
>
> The Royal Children's Hospital Melbourne
> 3 West Clinical Offices  |  50 Flemington Road   |   Parkville   |   3052   |  VIC
> T 03 9345 5182 |  E [log in to unmask]  |  F 03 9345 4751  |  W  www.rch.org.au/genmed
>
> -----Original Message-----
> From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Musab Yahia
> Sent: Wednesday, 9 October 2013 3:29 PM
> To: [log in to unmask]
> Subject: Bier Block
>
> Hi Everyone!
>
> I wanted to get input from anyone who's had experience using Bier blocks for fracture reductions. I've had several cases in the past couple of weeks where kids sustained a distal upper extremity fracture (which require reduction) and ate something shortly prior to ED arrival. Moderate sedation isnt an option and getting into the OR within a reasonable time frame isn't possible.
>
> 1. Is the Bier block practical for use in the ED? When used, how long after do you monitor the patient for?
> 2. Would you prefer it in fracture reductions versus if moderate sedation was an option?
> 3. Other than the potential of lidocaine causing an arrhythmia if improperly done, what complications have you seen from the Bier block?
>
> Any input is appreciated.
>
> Musab Al-Yahia, MD
> Gulf Coast Medical Center Emergency Room Panama City, Florida
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> ------------------------------
>
> Date:    Wed, 9 Oct 2013 12:13:13 -0400
> From:    "Alison Tothy, MD" <[log in to unmask]>
> Subject: University of Chicago Job Posting
>
> The Department of Pediatrics at the University of Chicago is recruiting faculty to join the fast growing section of Pediatric Emergency Medicine.
>
> Comer Children’s Hospital at the University of Chicago is a state-of-the-art children’s hospital.  Our teams of pediatric experts use advanced diagnostic and medical techniques to care for children of all ages.  The Pediatric Emergency Department, a Level 1 Pediatric Trauma Center on the South Side of Chicago, treats approximately 30,000 diverse patients a year.  It is a free standing children’s hospital within a larger medical center.  The seven year old facility has a total of 28 beds: 22 general exam rooms, two procedure rooms, two triage rooms and two trauma/resuscitation rooms.
>
> We are hiring faculty interested in joining a growing Academic Section with a newly accredited PEM Fellowship.  Faculty will be expected to hold or be eligible for licensure to practice medicine in the state of Illinois.  Applicants must be board certified/board eligible in Pediatric Emergency Medicine.  Clinical responsibilities include patient care and teaching of medical students and pediatric/emergency medicine house staff.  Successful applicants will enter an academic track within the University of Chicago and be expected to pursue a career in clinical care and research.  The development of an academic career in pediatric emergency medicine will be supported with resources and mentorship.  Academic rank and salary are commensurate with experience.  The University of Chicago is an affirmative action/equal opportunity employer.
>
> If any are interested, please send a letter of interest and curriculum vitae to the contact information below.
>
>
> Alison S. Tothy, MD
> Section Chief/Medical Director; Pediatric Emergency Medicine
> Department of Pediatrics
> University of Chicago
> Executive Medical Chief; Office of Patient Experience
> University of Chicago Medicine
> 5841 South Maryland Avenue, MC 0810
> Chicago, Illinois 60637
> phone: (773)702-3571
> fax: (773)702-0414
> pager: (773)845-5820
> [log in to unmask]
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> ------------------------------
>
> Date:    Wed, 9 Oct 2013 12:09:07 -0500
> From:    Martin Herman <[log in to unmask]>
> Subject: Re: Bier Block
>
> I have seen Bier blocks used without problems. However the literature on npo status is also replete with support for sedating without concern for when the kid ate. I think sedating with ketamine, versed and fentanyl is very different than GA and so is the risk of aspiration. Be cautious about the bier blocks bc of the low therapeutic index and risk of cuff failure. Alternative like an ancillary block or hematoma block are also viable options
>
> Marty
> Dr herman
>
> Sent from my iPhone
>
>> On Oct 9, 2013, at 6:42 AM, "Mike South" <[log in to unmask]> wrote:
>>
>> This is our Clinical Practice Guideline for Biers Block
>>
>> http://www.rch.org.au/clinicalguide/guideline_index/Biers_Block/
>>
>> Cheers
>>
>> Mike
>> Prof Mike South
>> Paediatrician & Intensivist,
>> Chief Medical Information Officer
>> Professor, University of Melbourne
>> Director, Department of General Medicine
>> Honorary Fellow, Murdoch Childrens Research Institute
>>
>>
>> The Royal Children's Hospital Melbourne
>> 3 West Clinical Offices  |  50 Flemington Road   |   Parkville   |   3052   |  VIC
>> T 03 9345 5182 |  E [log in to unmask]  |  F 03 9345 4751  |  W  www.rch.org.au/genmed
>>
>> -----Original Message-----
>> From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Musab Yahia
>> Sent: Wednesday, 9 October 2013 3:29 PM
>> To: [log in to unmask]
>> Subject: Bier Block
>>
>> Hi Everyone!
>>
>> I wanted to get input from anyone who's had experience using Bier blocks for fracture reductions. I've had several cases in the past couple of weeks where kids sustained a distal upper extremity fracture (which require reduction) and ate something shortly prior to ED arrival. Moderate sedation isnt an option and getting into the OR within a reasonable time frame isn't possible.
>>
>> 1. Is the Bier block practical for use in the ED? When used, how long after do you monitor the patient for?
>> 2. Would you prefer it in fracture reductions versus if moderate sedation was an option?
>> 3. Other than the potential of lidocaine causing an arrhythmia if improperly done, what complications have you seen from the Bier block?
>>
>> Any input is appreciated.
>>
>> Musab Al-Yahia, MD
>> Gulf Coast Medical Center Emergency Room Panama City, Florida
>>
>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:
>>                http://listserv.brown.edu/ped-em-l.html
>>
>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>> The URL for the PED-EM-L Web Page is:
>>                http://listserv.brown.edu/ped-em-l.html
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> ------------------------------
>
> Date:    Wed, 9 Oct 2013 12:39:56 -0500
> From:    Martin Herman <[log in to unmask]>
> Subject: Re: Bier Block
>
> I meant axillary block ( auto correct slipped that one by me!)
>
> So if the kid had a small meal or a light meal and the fracture needed reduction, I do sedate . Sometimes I'll pretreat with zantac to reduce stomach acid and  may also give 1 ounce Mylanta about an hour before the procedure.
> I would also argue that if the sedation doesn't seem safe, it is perfectly reasonable to splint in apposition of comfort and have the child return in the next couple of days ( preferably first thing in the AM) for a reduction. afterall there is no need to reduce a fracture acutely unless there is NV or skin compromise
>
>
>
> Marty
> Martin Herman, M.D.
>
> Pediatric Emergency Medicine
> Sacred Heart Children's Hospital
> Florida State University, Department of Pediatrics
> 5153 N. 9th Ave, 6th Floor Nemours Bldg
> Pensacola, FL 32504
> Ph: 850 416 7658(office)
> Email: [log in to unmask]
> CONFIDENTIALITY NOTICE:
> This email message and any accompanying data or files is confidential and may contain privileged information intended only for the named recipient(s). If you are not the intended recipient(s), you are hereby notified that the dissemination, distribution, and or copying of this message is strictly prohibited. If you receive this message in error, or are not the named recipient(s), please notify the sender at the email address above, delete this email from your computer, and destroy any copies in any form immediately. Receipt by anyone other than the named recipient(s) is not a waiver of any attorney-client, work product, or other applicable privilege.
>
>
>
>
>
>> Date: Wed, 9 Oct 2013 12:09:07 -0500
>> From: [log in to unmask]
>> Subject: Re: Bier Block
>> To: [log in to unmask]
>>
>> I have seen Bier blocks used without problems. However the literature on npo status is also replete with support for sedating without concern for when the kid ate. I think sedating with ketamine, versed and fentanyl is very different than GA and so is the risk of aspiration. Be cautious about the bier blocks bc of the low therapeutic index and risk of cuff failure. Alternative like an ancillary block or hematoma block are also viable options
>>
>> Marty
>> Dr herman
>>
>> Sent from my iPhone
>>
>>> On Oct 9, 2013, at 6:42 AM, "Mike South" <[log in to unmask]> wrote:
>>>
>>> This is our Clinical Practice Guideline for Biers Block
>>>
>>> http://www.rch.org.au/clinicalguide/guideline_index/Biers_Block/
>>>
>>> Cheers
>>>
>>> Mike
>>> Prof Mike South
>>> Paediatrician & Intensivist,
>>> Chief Medical Information Officer
>>> Professor, University of Melbourne
>>> Director, Department of General Medicine
>>> Honorary Fellow, Murdoch Childrens Research Institute
>>>
>>>
>>> The Royal Children's Hospital Melbourne
>>> 3 West Clinical Offices  |  50 Flemington Road   |   Parkville   |   3052   |  VIC
>>> T 03 9345 5182 |  E [log in to unmask]  |  F 03 9345 4751  |  W  www.rch.org.au/genmed
>>>
>>> -----Original Message-----
>>> From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Musab Yahia
>>> Sent: Wednesday, 9 October 2013 3:29 PM
>>> To: [log in to unmask]
>>> Subject: Bier Block
>>>
>>> Hi Everyone!
>>>
>>> I wanted to get input from anyone who's had experience using Bier blocks for fracture reductions. I've had several cases in the past couple of weeks where kids sustained a distal upper extremity fracture (which require reduction) and ate something shortly prior to ED arrival. Moderate sedation isnt an option and getting into the OR within a reasonable time frame isn't possible.
>>>
>>> 1. Is the Bier block practical for use in the ED? When used, how long after do you monitor the patient for?
>>> 2. Would you prefer it in fracture reductions versus if moderate sedation was an option?
>>> 3. Other than the potential of lidocaine causing an arrhythmia if improperly done, what complications have you seen from the Bier block?
>>>
>>> Any input is appreciated.
>>>
>>> Musab Al-Yahia, MD
>>> Gulf Coast Medical Center Emergency Room Panama City, Florida
>>>
>>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:
>>>                http://listserv.brown.edu/ped-em-l.html
>>>
>>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>>> The URL for the PED-EM-L Web Page is:
>>>                http://listserv.brown.edu/ped-em-l.html
>>
>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>> The URL for the PED-EM-L Web Page is:
>>                 http://listserv.brown.edu/ped-em-l.html
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> ------------------------------
>
> Date:    Wed, 9 Oct 2013 19:21:59 +0000
> From:    "Gerardi, Michael" <[log in to unmask]>
> Subject: Re: Bier Block
>
> Hi Marty and All
>
> Referring to the low therapeutic index, I have heard Al Sacchetti lecture on this using his own experience. He espouses using a back-up BP cuff / tourniquet in case one fails.
>
> Mike
>
> Michael Gerardi, MD, FAAP, FACEP
>
>
> ________________________________________
> From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] on behalf of Martin Herman [[log in to unmask]]
> Sent: Wednesday, October 09, 2013 1:09 PM
> To: [log in to unmask]
> Subject: Re: Bier Block
>
> I have seen Bier blocks used without problems. However the literature on npo status is also replete with support for sedating without concern for when the kid ate. I think sedating with ketamine, versed and fentanyl is very different than GA and so is the risk of aspiration. Be cautious about the bier blocks bc of the low therapeutic index and risk of cuff failure. Alternative like an ancillary block or hematoma block are also viable options
>
> Marty
> Dr herman
>
> Sent from my iPhone
>
>> On Oct 9, 2013, at 6:42 AM, "Mike South" <[log in to unmask]> wrote:
>>
>> This is our Clinical Practice Guideline for Biers Block
>>
>> http://www.rch.org.au/clinicalguide/guideline_index/Biers_Block/
>>
>> Cheers
>>
>> Mike
>> Prof Mike South
>> Paediatrician & Intensivist,
>> Chief Medical Information Officer
>> Professor, University of Melbourne
>> Director, Department of General Medicine
>> Honorary Fellow, Murdoch Childrens Research Institute
>>
>>
>> The Royal Children's Hospital Melbourne
>> 3 West Clinical Offices  |  50 Flemington Road   |   Parkville   |   3052   |  VIC
>> T 03 9345 5182 |  E [log in to unmask]  |  F 03 9345 4751  |  W  www.rch.org.au/genmed
>>
>> -----Original Message-----
>> From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Musab Yahia
>> Sent: Wednesday, 9 October 2013 3:29 PM
>> To: [log in to unmask]
>> Subject: Bier Block
>>
>> Hi Everyone!
>>
>> I wanted to get input from anyone who's had experience using Bier blocks for fracture reductions. I've had several cases in the past couple of weeks where kids sustained a distal upper extremity fracture (which require reduction) and ate something shortly prior to ED arrival. Moderate sedation isnt an option and getting into the OR within a reasonable time frame isn't possible.
>>
>> 1. Is the Bier block practical for use in the ED? When used, how long after do you monitor the patient for?
>> 2. Would you prefer it in fracture reductions versus if moderate sedation was an option?
>> 3. Other than the potential of lidocaine causing an arrhythmia if improperly done, what complications have you seen from the Bier block?
>>
>> Any input is appreciated.
>>
>> Musab Al-Yahia, MD
>> Gulf Coast Medical Center Emergency Room Panama City, Florida
>>
>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:
>>                http://listserv.brown.edu/ped-em-l.html
>>
>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>> The URL for the PED-EM-L Web Page is:
>>                http://listserv.brown.edu/ped-em-l.html
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
>
>
> The information contained in this email is intended only for the use of the person(s) identified above. This communication may contain work product which is privileged and confidential, and may contain content which is regulated by Federal law. If you are not an intended recipient or the employee or agent responsible to deliver this to the intended recipient, you have received this message in error and any review, distribution or copying of it by you is prohibited. If you have received this message in error, please notify the sender immediately, and delete the message. E-mail and communication system messages generated by members of the Atlantic Health System workforce may not necessarily reflect the views of Atlantic Health System, its officers, directors or management.
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> ------------------------------
>
> Date:    Wed, 9 Oct 2013 15:20:37 -0500
> From:    Martin Herman <[log in to unmask]>
> Subject: Re: Bier Block
>
> Mike that is A great safe guard. Are you using Bier blocks or sedating in spite of not being npo in compliance with the Asa guidelines? Or do you defer reductions etc till the kid meets npo guidelines?
>
> Sent from my iPhone
>
>> On Oct 9, 2013, at 2:30 PM, "Gerardi, Michael" <[log in to unmask]> wrote:
>>
>> Hi Marty and All
>>
>> Referring to the low therapeutic index, I have heard Al Sacchetti lecture on this using his own experience. He espouses using a back-up BP cuff / tourniquet in case one fails.
>>
>> Mike
>>
>> Michael Gerardi, MD, FAAP, FACEP
>>
>>
>> ________________________________________
>> From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] on behalf of Martin Herman [[log in to unmask]]
>> Sent: Wednesday, October 09, 2013 1:09 PM
>> To: [log in to unmask]
>> Subject: Re: Bier Block
>>
>> I have seen Bier blocks used without problems. However the literature on npo status is also replete with support for sedating without concern for when the kid ate. I think sedating with ketamine, versed and fentanyl is very different than GA and so is the risk of aspiration. Be cautious about the bier blocks bc of the low therapeutic index and risk of cuff failure. Alternative like an ancillary block or hematoma block are also viable options
>>
>> Marty
>> Dr herman
>>
>> Sent from my iPhone
>>
>>> On Oct 9, 2013, at 6:42 AM, "Mike South" <[log in to unmask]> wrote:
>>>
>>> This is our Clinical Practice Guideline for Biers Block
>>>
>>> http://www.rch.org.au/clinicalguide/guideline_index/Biers_Block/
>>>
>>> Cheers
>>>
>>> Mike
>>> Prof Mike South
>>> Paediatrician & Intensivist,
>>> Chief Medical Information Officer
>>> Professor, University of Melbourne
>>> Director, Department of General Medicine
>>> Honorary Fellow, Murdoch Childrens Research Institute
>>>
>>>
>>> The Royal Children's Hospital Melbourne
>>> 3 West Clinical Offices  |  50 Flemington Road   |   Parkville   |   3052   |  VIC
>>> T 03 9345 5182 |  E [log in to unmask]  |  F 03 9345 4751  |  W  www.rch.org.au/genmed
>>>
>>> -----Original Message-----
>>> From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Musab Yahia
>>> Sent: Wednesday, 9 October 2013 3:29 PM
>>> To: [log in to unmask]
>>> Subject: Bier Block
>>>
>>> Hi Everyone!
>>>
>>> I wanted to get input from anyone who's had experience using Bier blocks for fracture reductions. I've had several cases in the past couple of weeks where kids sustained a distal upper extremity fracture (which require reduction) and ate something shortly prior to ED arrival. Moderate sedation isnt an option and getting into the OR within a reasonable time frame isn't possible.
>>>
>>> 1. Is the Bier block practical for use in the ED? When used, how long after do you monitor the patient for?
>>> 2. Would you prefer it in fracture reductions versus if moderate sedation was an option?
>>> 3. Other than the potential of lidocaine causing an arrhythmia if improperly done, what complications have you seen from the Bier block?
>>>
>>> Any input is appreciated.
>>>
>>> Musab Al-Yahia, MD
>>> Gulf Coast Medical Center Emergency Room Panama City, Florida
>>>
>>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:
>>>               http://listserv.brown.edu/ped-em-l.html
>>>
>>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>>> The URL for the PED-EM-L Web Page is:
>>>               http://listserv.brown.edu/ped-em-l.html
>>
>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>> The URL for the PED-EM-L Web Page is:
>>                http://listserv.brown.edu/ped-em-l.html
>>
>>
>>
>> The information contained in this email is intended only for the use of the person(s) identified above. This communication may contain work product which is privileged and confidential, and may contain content which is regulated by Federal law. If you are not an intended recipient or the employee or agent responsible to deliver this to the intended recipient, you have received this message in error and any review, distribution or copying of it by you is prohibited. If you have received this message in error, please notify the sender immediately, and delete the message. E-mail and communication system messages generated by members of the Atlantic Health System workforce may not necessarily reflect the views of Atlantic Health System, its officers, directors or management.
>>
>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>> The URL for the PED-EM-L Web Page is:
>>                http://listserv.brown.edu/ped-em-l.html
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> ------------------------------
>
> Date:    Wed, 9 Oct 2013 16:46:04 -0400
> From:    Michael Falk <[log in to unmask]>
> Subject: Re: Bier Block
>
> Two points: agree with Marty...data for "npo" and procedural sedation  is
> lacking and would still do it if I felt it was necessary.  Second, why not
> do US guided or "old school", nerve block?  Both are very effective and
> easily done in the ER for many isolated extremity fractures.
> Mike Falk
> New York.
>
>
> On Wed, Oct 9, 2013 at 4:20 PM, Martin Herman <[log in to unmask]>wrote:
>
>> Mike that is A great safe guard. Are you using Bier blocks or sedating in
>> spite of not being npo in compliance with the Asa guidelines? Or do you
>> defer reductions etc till the kid meets npo guidelines?
>>
>> Sent from my iPhone
>>
>>> On Oct 9, 2013, at 2:30 PM, "Gerardi, Michael" <
>> [log in to unmask]> wrote:
>>>
>>> Hi Marty and All
>>>
>>> Referring to the low therapeutic index, I have heard Al Sacchetti
>> lecture on this using his own experience. He espouses using a back-up BP
>> cuff / tourniquet in case one fails.
>>>
>>> Mike
>>>
>>> Michael Gerardi, MD, FAAP, FACEP
>>>
>>>
>>> ________________________________________
>>> From: Pediatric Emergency Medicine Discussion List [
>> [log in to unmask]] on behalf of Martin Herman [
>> [log in to unmask]]
>>> Sent: Wednesday, October 09, 2013 1:09 PM
>>> To: [log in to unmask]
>>> Subject: Re: Bier Block
>>>
>>> I have seen Bier blocks used without problems. However the literature on
>> npo status is also replete with support for sedating without concern for
>> when the kid ate. I think sedating with ketamine, versed and fentanyl is
>> very different than GA and so is the risk of aspiration. Be cautious about
>> the bier blocks bc of the low therapeutic index and risk of cuff failure.
>> Alternative like an ancillary block or hematoma block are also viable
>> options
>>>
>>> Marty
>>> Dr herman
>>>
>>> Sent from my iPhone
>>>
>>>> On Oct 9, 2013, at 6:42 AM, "Mike South" <[log in to unmask]> wrote:
>>>>
>>>> This is our Clinical Practice Guideline for Biers Block
>>>>
>>>> http://www.rch.org.au/clinicalguide/guideline_index/Biers_Block/
>>>>
>>>> Cheers
>>>>
>>>> Mike
>>>> Prof Mike South
>>>> Paediatrician & Intensivist,
>>>> Chief Medical Information Officer
>>>> Professor, University of Melbourne
>>>> Director, Department of General Medicine
>>>> Honorary Fellow, Murdoch Childrens Research Institute
>>>>
>>>>
>>>> The Royal Children's Hospital Melbourne
>>>> 3 West Clinical Offices  |  50 Flemington Road   |   Parkville   |
>> 3052   |  VIC
>>>> T 03 9345 5182 |  E [log in to unmask]  |  F 03 9345 4751  |  W
>> www.rch.org.au/genmed
>>>>
>>>> -----Original Message-----
>>>> From: Pediatric Emergency Medicine Discussion List [mailto:
>> [log in to unmask]] On Behalf Of Musab Yahia
>>>> Sent: Wednesday, 9 October 2013 3:29 PM
>>>> To: [log in to unmask]
>>>> Subject: Bier Block
>>>>
>>>> Hi Everyone!
>>>>
>>>> I wanted to get input from anyone who's had experience using Bier
>> blocks for fracture reductions. I've had several cases in the past couple
>> of weeks where kids sustained a distal upper extremity fracture (which
>> require reduction) and ate something shortly prior to ED arrival. Moderate
>> sedation isnt an option and getting into the OR within a reasonable time
>> frame isn't possible.
>>>>
>>>> 1. Is the Bier block practical for use in the ED? When used, how long
>> after do you monitor the patient for?
>>>> 2. Would you prefer it in fracture reductions versus if moderate
>> sedation was an option?
>>>> 3. Other than the potential of lidocaine causing an arrhythmia if
>> improperly done, what complications have you seen from the Bier block?
>>>>
>>>> Any input is appreciated.
>>>>
>>>> Musab Al-Yahia, MD
>>>> Gulf Coast Medical Center Emergency Room Panama City, Florida
>>>>
>>>> For more information, send mail to [log in to unmask] with
>> the message: info PED-EM-L The URL for the PED-EM-L Web Page is:
>>>>               http://listserv.brown.edu/ped-em-l.html
>>>>
>>>> For more information, send mail to [log in to unmask] with
>> the message: info PED-EM-L
>>>> The URL for the PED-EM-L Web Page is:
>>>>               http://listserv.brown.edu/ped-em-l.html
>>>
>>> For more information, send mail to [log in to unmask] with the
>> message: info PED-EM-L
>>> The URL for the PED-EM-L Web Page is:
>>>                http://listserv.brown.edu/ped-em-l.html
>>>
>>>
>>>
>>> The information contained in this email is intended only for the use of
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>> which is privileged and confidential, and may contain content which is
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>>>
>>> For more information, send mail to [log in to unmask] with the
>> message: info PED-EM-L
>>> The URL for the PED-EM-L Web Page is:
>>>                http://listserv.brown.edu/ped-em-l.html
>>
>> For more information, send mail to [log in to unmask] with the
>> message: info PED-EM-L
>> The URL for the PED-EM-L Web Page is:
>>                 http://listserv.brown.edu/ped-em-l.html
>>
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> ------------------------------
>
> Date:    Wed, 9 Oct 2013 21:41:23 +0000
> From:    Doc Holiday <[log in to unmask]>
> Subject: Re: Bier Block
>
> From: Musab Yahia> Is the Bier block practical for use in the ED?
> --> Very!
> And I don't actually like to do it much; some colleagues do more. So I am not trying to "sell" it, but my not using it is NOT because it is impractical! A very good option.
>> When used, how long after do you monitor the patient for?
> --> Patient may leave as soon as cuff is deflated. No need to monitor after that.
>> Would you prefer it in fracture reductions versus if moderate sedation was an option?
> --> No, but this is personal preference and I would not claim sedation is BETTER - there is simply more than one way and I prefer sedation. I also do nerve blocks, axillary blocks and haematoma blocks. I do like the latter, especially in adults.
>> Other than the potential of lidocaine causing an arrhythmia if improperly done, what complications have you seen from the Bier block?
> --> No complications.
> Please note that there was a full stop after the "no complications" bit. That's that!
> Of course, this may well be because I have not used lidocaine/lignocaine for this since the early 90s. Prilocaine is agent of choice. MUCH less likely to cause arrhythmia or other side effects and I am not aware of any. Reports are that they did not even occur with accidental cuff deflation or even when cuff was not inflated at all.
> From: Martin Herman ([log in to unmask])> Be cautious about the bier blocks bc of the low therapeutic index and risk of cuff failure
> --> Not such an issue with Prilocaine.
> Use of double-cuff machines should take care of the cuff failure issue.
> Ideal machines are those with ACTIVE deflation, i.e. if you pull the cuff tube out of the machine it stays inflated - the machine is required in order to RELEASE the pressure! So no accidental deflation and no need for back-up cuffs, as the 2nd cuff is built in. Not sure one can still purchase a single-cuff version in the UK (nor would anyone want to!).
> Also no need for significant starving with Bier's blocks. When they try to compare the incidence of vomits with prilocaine and short vs. long starvation, e.g. 3hrs vs 6hrs, the study suffered from the complete absence of vomits in both groups...
> Also, of course, with Bier's block, if there was a vomit, it's NOT in a sedated patient, which is relevant for aspiration.
> Good idea to apply topical EMLA/Ametop at site of IV cannula, but local ice application also works.
> Hope this helps. Lots of stuff on line for this.
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> ------------------------------
>
> Date:    Wed, 9 Oct 2013 21:56:34 +0000
> From:    Doc Holiday <[log in to unmask]>
> Subject: Re: Bier Block
>
> From: Musab Yahia
>
>> Is the Bier block practical for use in the ED?
>
> --> Very!
>
> And I don't actually like to do it much; some colleagues do more. So I am not trying to "sell" it, but my not using it is NOT because it is impractical! A very good option.
>
>> When used, how long after do you monitor the patient for?
>
> --> Patient may leave as soon as cuff is deflated. No need to monitor after that.
>
>> Would you prefer it in fracture reductions versus if moderate sedation was an option?
>
> --> No, but this is personal preference and I would not claim sedation is BETTER - there is simply more than one way and I prefer sedation. I also do nerve blocks, axillary blocks and haematoma blocks. I do like the latter, especially in adults.
>
>> Other than the potential of lidocaine causing an arrhythmia if improperly done, what complications have you seen from the Bier block?
>
> --> No complications.
>
> Please note that there was a full stop after the "no complications" bit. That's that!
>
> Of course, this may well be because I have not used lidocaine/lignocaine for this since the early 90s. Prilocaine is agent of choice. MUCH less likely to cause arrhythmia or other side effects and I am not aware of any. Reports are that they did not even occur with accidental cuff deflation or even when cuff was not inflated at all.
>
> From: Martin Herman ([log in to unmask])
>> Be cautious about the bier blocks bc of the low therapeutic index and risk of cuff failure
>
> --> Not such an issue with Prilocaine.
>
> Use of double-cuff machines should take care of the cuff failure issue.
>
> Ideal machines are those with ACTIVE deflation, i.e. if you pull the cuff tube out of the machine it stays inflated - the machine is required in order to RELEASE the pressure! So no accidental deflation and no need for back-up cuffs, as the 2nd cuff is built in. Not sure one can still purchase a single-cuff version in the UK (nor would anyone want to!).
>
> Also no need for significant starving with Bier's blocks. When they try to compare the incidence of vomits with prilocaine and short vs. long starvation, e.g. 3hrs vs 6hrs, the study suffered from the complete absence of vomits in both groups...
>
> Also, of course, with Bier's block, if there was a vomit, it's NOT in a sedated patient, which is relevant for aspiration.
>
> Good idea to apply topical EMLA/Ametop at site of IV cannula, but local ice application also works.
>
> Hope this helps. Lots of stuff on line for this.
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> ------------------------------
>
> Date:    Thu, 10 Oct 2013 10:37:41 +1100
> From:    Franz Babl <[log in to unmask]>
> Subject: Re: Bier Block
>
> Bier's block in kids and administered by ED docs for reduction by ED docs is used relatively widely in Australia.
> The attraction is complete anaesthesia and immediate discharge readiness.
> I prefer over sedation due to above, but child needs to be not freaked out- reaction to having IV placed is a good guide-  then sedation better.
> We only use lidocaine and single cuff. Double cuff in small arms is more difficult to apply- better one good big cuff.
> See CPG for Bier's per posting Mike South same string.
> Best
> Franz E Babl
> Royal Children's Hospital
> Melbourne, Australia
>
> ________________________________________
> From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] On Behalf Of Musab Yahia [[log in to unmask]]
> Sent: Wednesday, 9 October 2013 3:29 PM
> To: [log in to unmask]
> Subject: Bier Block
>
> Hi Everyone!
>
> I wanted to get input from anyone who's had experience using Bier blocks for fracture reductions. I've had several cases in the past couple of weeks where kids sustained a distal upper extremity fracture (which require reduction) and ate something shortly prior to ED arrival. Moderate sedation isnt an option and getting into the OR within a reasonable time frame isn't possible.
>
> 1. Is the Bier block practical for use in the ED? When used, how long after do you monitor the patient for?
> 2. Would you prefer it in fracture reductions versus if moderate sedation was an option?
> 3. Other than the potential of lidocaine causing an arrhythmia if improperly done, what complications have you seen from the Bier block?
>
> Any input is appreciated.
>
> Musab Al-Yahia, MD
> Gulf Coast Medical Center Emergency Room
> Panama City, Florida
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> ------------------------------
>
> Date:    Wed, 9 Oct 2013 19:31:33 -0400
> From:    Adam Bretholz <[log in to unmask]>
> Subject: Re: Bier Block
>
> Dear Dr. Al-Yahia and Colleagues,
>
> I am a long time observer, but this is my first post.
>
> I agree with the previous posts that eating prior to reduction wouldn’t
> necessarily preclude me from doing a sedation. However, I understand your
> predicament as the previous hospital where I worked was quite strict on NPO
> status.
>
> I am quite familiar with Bier blocks and helped to institute them in our
> tertiary care PED last year (Montreal Children’s Hospital, roughly 80,000
> visits per year).  Since starting the program we are approaching our first
> hundred patients (nothing compared to Melbourne who have been doing them
> for decades). I am admittedly biased by our positive experience with Bier
> blocks, and would like to weigh in on the discussion.
>
> 1. Is the Bier block practical for use in the ED? When used, how long after
> do you monitor the patient for?
>
> Yes. It is safe, efficient and family-centered.  We monitor for 20 minutes
> post procedure, but this is a little arbitrary. This gives us time to get a
> confirmatory x-ray and check the cast.
>
> 2. Would you prefer it in fracture reductions versus if moderate sedation
> was an option?
>
> Personally yes, but it depends on the patient, however this may be a
> function of our PED’s limited access to moderate sedation options.
>
> 3. Other than the potential of lidocaine causing an arrhythmia if
> improperly done, what complications have you seen from the Bier block?
>
> Our personal experience has been very reassuring, but you need the right
> safe guards and equipment in place. I would recommend using a Zimmer
> automatic tourniquet if you are going to be regularly doing this procedure.
> Potential complications can include not only cardiac but also CNS effects
> and local pressure effects.
>
> I am happy to speak further off –line if you are interested. Please contact
> me via email.
>
> In addition I am interested in collaborating with other institutions that
> are doing Bier blocks in the PED on a regular basis. Please contact me if
> you are interested.
>
>
> Adam Bretholz, MD, FRCP
>
> Monteal Children’s Hospital
>
>
>> On Wed, Oct 9, 2013 at 12:29 AM, Musab Yahia <[log in to unmask]> wrote:
>>
>> Hi Everyone!
>>
>> I wanted to get input from anyone who's had experience using Bier blocks
>> for fracture reductions. I've had several cases in the past couple of weeks
>> where kids sustained a distal upper extremity fracture (which require
>> reduction) and ate something shortly prior to ED arrival. Moderate sedation
>> isnt an option and getting into the OR within a reasonable time frame isn't
>> possible.
>>
>> 1. Is the Bier block practical for use in the ED? When used, how long
>> after do you monitor the patient for?
>> 2. Would you prefer it in fracture reductions versus if moderate sedation
>> was an option?
>> 3. Other than the potential of lidocaine causing an arrhythmia if
>> improperly done, what complications have you seen from the Bier block?
>>
>> Any input is appreciated.
>>
>> Musab Al-Yahia, MD
>> Gulf Coast Medical Center Emergency Room
>> Panama City, Florida
>>
>> For more information, send mail to [log in to unmask] with the
>> message: info PED-EM-L
>> The URL for the PED-EM-L Web Page is:
>>                 http://listserv.brown.edu/ped-em-l.html
>>
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> ------------------------------
>
> Date:    Wed, 9 Oct 2013 19:45:15 -0400
> From:    Amy Baxter <[log in to unmask]>
> Subject: Re: Bier Block
>
> We do Bier blocks frequently in our 100K volume ED, and an orthopedic resident did a nice comparison of sedation v. Bier.  He successfully presented the research as a platform, but had more trouble when he submitted the paper.  The reviews were harsh -- critiques of theoretical safety concerns not addressed with the 400+ cases -- and I don't believe he's pursued revising and publishing.  Pity.  It  seemed to me the concerns of the orthopedic reviewers were more theoretical and hearsay than literature based.  We've found that a small amount of midazolam helps the anxious ones, and as Dr. Babl notes the IV is a good litmus test.
>
> Of note, we also cast almost all of our fractures rather than splinting... ooh!  Heresy!
>
> Sent from my iPad
>
>> On Oct 9, 2013, at 7:37 PM, Franz Babl <[log in to unmask]> wrote:
>>
>> Bier's block in kids and administered by ED docs for reduction by ED docs is used relatively widely in Australia.
>> The attraction is complete anaesthesia and immediate discharge readiness.
>> I prefer over sedation due to above, but child needs to be not freaked out- reaction to having IV placed is a good guide-  then sedation better.
>> We only use lidocaine and single cuff. Double cuff in small arms is more difficult to apply- better one good big cuff.
>> See CPG for Bier's per posting Mike South same string.
>> Best
>> Franz E Babl
>> Royal Children's Hospital
>> Melbourne, Australia
>>
>> ________________________________________
>> From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] On Behalf Of Musab Yahia [[log in to unmask]]
>> Sent: Wednesday, 9 October 2013 3:29 PM
>> To: [log in to unmask]
>> Subject: Bier Block
>>
>> Hi Everyone!
>>
>> I wanted to get input from anyone who's had experience using Bier blocks for fracture reductions. I've had several cases in the past couple of weeks where kids sustained a distal upper extremity fracture (which require reduction) and ate something shortly prior to ED arrival. Moderate sedation isnt an option and getting into the OR within a reasonable time frame isn't possible.
>>
>> 1. Is the Bier block practical for use in the ED? When used, how long after do you monitor the patient for?
>> 2. Would you prefer it in fracture reductions versus if moderate sedation was an option?
>> 3. Other than the potential of lidocaine causing an arrhythmia if improperly done, what complications have you seen from the Bier block?
>>
>> Any input is appreciated.
>>
>> Musab Al-Yahia, MD
>> Gulf Coast Medical Center Emergency Room
>> Panama City, Florida
>>
>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>> The URL for the PED-EM-L Web Page is:
>>                http://listserv.brown.edu/ped-em-l.html
>>
>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>> The URL for the PED-EM-L Web Page is:
>>                http://listserv.brown.edu/ped-em-l.html
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> ------------------------------
>
> End of PED-EM-L Digest - 8 Oct 2013 to 9 Oct 2013 (#2013-219)
> *************************************************************
________________________________

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