Place double cuff tourniquet on upper arm and not on forearm as adequate arterial compression cannot be obtained; padding must always be applied prior to cuff placement and applying a well fitted double cuff will be a 2 person procedure.
If a plaster has already been applied then apply tourniquet before removing the plaster.
Elevate the injured arm to exsanguinate the limb.
Inflate the proximal cuff to 100 mmHg above the systolic BP (up to a maximum of 300 mmHg); if rotation of cuff is considered then the machine should have a fail-safe selected preventing decompression of proximal cuff prior to inflation of distal cuff.
Record the time of inflation.
Check for the absence of a radial pulse.
Inject 0.5% plain prilocaine, prepared according to patient weight, slowly and record the time of injection.
Remove the cannula and apply pressure as the venepuncture site is prone to bleeding (thus use of 22G).
Warn the patient about the cold/hot sensation and mottled appearance of the arm.
Check for anaesthesia, the patient may sense movement but not pain after 10 minutes which is when the manipulation should be done and the plaster applied by 2nd member of staff.
Lower the arm on to a pillow and obtain a check x-ray.
Tourniquet dials must be under observation at all times.
The cuff must be inflated for a minimum of 20 minutes and a maximum of 45 minutes.
If rotation of cuff is required because of pain at cuff site or a prolonged procedure (2nd manipulation), this should done after the manipulation and plaster is applied; the distal cuff will then be inflated over an anaesthetised area and be more comfortable for the patient.
If satisfied with the post reduction position of fracture, deflate the cuff observing the patient and monitor.
If fail safe selection applied the distal cuff will need to be inflated first prior to deflations.
Record the time of deflation.
Check limb circulation prior to discharge and arrange patient follow up and analgesia as appropriate.