POTD: Fishhook Injury

Hi everyone,

Caroline and I have the great privilege of serving as your admin residents for this upcoming block. Throughout the next four weeks, if there are any topics floating in your head that you would like us to dive further into, send it our way!

For today's POTD, I wanted to explore the unfortunate case of a fishhook injury, with a particular focus on fishhook removal techniques if it ever maneuvers its way into your ED. Over the weekend, the south side team successfully removed a fishhook lodged in a patient's pinky finger, and, by the leadership of Dr. Sanjeevan and the grip strength of Dr. Weber, the patient was able to ambulate out of the ED with all digits intact and ready for another day of fishing in Red Hook.

Fishhook Anatomy

A fishhook is composed of the eyelet, shank, belly, barb, and tip. Most fishhooks are J hooks, with one shank and one barb, but occasionally you might see a treble hook, which is essentially multiple J hooks together all sharing a shank. The real troublemaker for fishhook injuries is the barb. Fear the barb. The sharp, reversed nature of the barb makes it so that a simple retrograde removal would be traumatic both to the surrounding tissue and the patient.

Preparation

1) Assess path of fishhook: Your removal technique will in part depend on the depth and location of the needle. Is the distal tip already near the surface? Is it going to hit any important structures on its way in or out? You may need further imaging to better clarify the track it took. If it involves the eye, consult ophtho. If it involves bone or tendon, consult ortho.

2) Local anesthetic/nerve block: Digital blocks work great for these when applicable.

3) Wound cleaning: Chlorhexidine or betadine like wild.

Techniques

1) Advance and Cut Technique: need hemostat, wire cutters/raptors, gauze, eye protection

a. Anesthetize.

b. Advance the fishhook further into the patient until the tip and the barb have both exited the skin.

c. Cut the barb off the fishhook with wire cutters or raptors. If using raptors, you can use the ring cutter function (shown below). Make sure you keep gauze over the barb and have eye protection on before you cut so as to avoid the cut barb from flying off and causing further injuries.

d. Reverse the hook back out of the skin.

2) String Technique: need string or strong suture, eye protection

a. Wrap a string or strong suture around the fishhook.

b. Push down on the shank to dislodge the barb as much as possible.

c. Pull on the string and jerk quickly. Watch out for the fishhook to come flying out of the skin.

3) Needle Technique: need 18 gauge needle

a. Anesthetize.

b. Advance an 18 gauge needle along the fishhook toward the tip and over the barb.

c. Reverse out both the needle and fishhook together as a unit.

4) Scalpel Technique: need scalpel, hemostat

a. Anesthetize.

b. Use #11 blade scalpel to cut down to the barb.

c. Grab barb with hemostat.

c. Pull entire fishhook up and out.

Post-Removal Care

1) Check for foreign bodies: Consider xray if any concern for retained objects.

2) Tetanus: Hit them with that tdap as indicated. 

3) Antibiotics: No trials have been done to study PO antibiotics after fishhook injury. You might consider adding on systemic antibiotics for immunocompromised folks, infection-prone areas, or contaminated hooks. At the very least, topical bacitracin and instructions on local wound care are always a good call.

Happy fishing,

Kelsey

Resources:

1) https://www.aliem.com/trick-fishhook-removal-techniques/

2) https://www.uptodate.com/contents/fish-hook-removal-techniques?search=fish%20hook%20removal&source=search_result&selectedTitle=1%7E1&usage_type=default&display_rank=1#H13

3) https://www.tampaemergencymedicine.org/blog/fish-hook-removal

4) https://www.emra.org/emresident/article/angling-for-success-techniques-for-fishhook-removal-in-the-ed

5) https://www.emrap.org/episode/ucprocedures/ucproceduresfishhookremoval

6) https://www.emrap.org/episode/fishhookremoval1/fishhookremoval1

7) https://www.emrap.org/episode/fishhookremoval/fishhookremoval

Snake Bites

Coral snake bites are relatively rare but potentially serious envenomations caused by the bites of venomous coral snakes, belonging to the Elapidae family. The most prevalent coral snake species in North America is the Eastern Coral Snake (Micrurus fulvius). They are the classic “red touch yellow, kill a fellow.” Here is a summary of key aspects related to coral snake bites:

Mechanism of Toxin: Coral snake venom primarily consists of neurotoxins that affect the nervous system. These neurotoxins which include micrurotoxin and micruroidin, target the neuromuscular junction at acetylcholine receptors, to which they inhibit. This can lead to respiratory depression.

Clinical Features of Coral Snake Bites:

1. Local Symptoms: Coral snake bites often do not cause significant local symptoms, such as pain or swelling, unlike many other venomous snake bites.

2. Neurological Symptoms: The primary clinical manifestation is neurotoxicity, characterized by weakness, difficulty swallowing, slurred speech, and respiratory failure. Patients can develop cranial nerve palsies.

3. Respiratory Distress: Resulting from respiratory muscle paralysis. This is the primary concern after a coral snake bite.

Evaluation and Lab Abnormalities:

1. Clinical Assessment: Diagnosis is primarily clinical, based on the characteristic neurological symptoms and a history of coral snake bite.

2. Laboratory Tests: Laboratory abnormalities may include an elevated creatine kinase (CK) level due to muscle breakdown, reflecting the neurotoxic effects of the venom.

3. Coagulation Studies: Unlike some other venomous snake bites, coral snake envenomation usually does not cause coagulopathy. There are rare reported cases of DIC in coral snake bites, and given that patients may not remember the type of snake that bit them, it is not unreasonable to send DIC labs.

Medical Management:

1. Supportive Care: Normal wound care, clean the wound, update tetanus, watch for cellulitis. Do not attempt to “suck out” the venom. No indication for using a tourniquet. Extremities should be monitored for compartment syndrome.

2. Antivenom: The only specific treatment for coral snake envenomation is the administration of coral snake antivenom (Micrurus fulvius antivenom). However, this has been out of production and current stock is expected to end this year.

3. Ventilatory Support: Patients with respiratory failure may require mechanical ventilation until the effects of the venom wear off. This should be handled aggressively. If the patient shows any signs of respiratory failure, promptly intubate them.

It's important to note that coral snake bites are uncommon, and the severity of envenomation can vary. These patients often require admission for monitoring.

Crotaline bites, commonly referred to as snakebites from pit vipers such as rattlesnakes, copperheads, and cottonmouths, are the other clinically significant snakes in NA. Here's a summary covering the mechanism of toxin, clinical features, evaluation, and medical management:

Mechanism of Toxin: Crotaline venom primarily consists of enzymes and peptides that exert cytotoxic, hemotoxic, and proteolytic effects. Metalloproteinases and serine proteinases in the venom contribute to swelling and damage to capillaries. They also lead to coagulation abnormalities. 

Clinical Features of Crotaline Bites:

1.       Local Effects: Immediate pain, swelling, and ecchymosis at the bite site. Local tissue necrosis may occur, especially with rattlesnake bites.

2.       Systemic Effects: Hematologic abnormalities, such as thrombocytopenia and coagulopathy, due to venom-induced consumption coagulopathy. Systemic symptoms like nausea, vomiting, weakness, dizziness, and diaphoresis also occur. Severe envenomation can lead to shock, respiratory distress, and organ failure.

Evaluation, Including Lab Abnormalities:

1.       Clinical Assessment: Assess local and systemic signs of envenomation. Evaluate for signs of compartment syndrome in the affected limb. Patients can develop hypotension from significant third spacing.

2.       Laboratory Studies: Complete blood count (CBC) to assess for thrombocytopenia and coagulopathy. Coagulation studies, including prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen levels. Blood chemistry to assess organ function.

Medical Management:

1.       Supportive Care: Normal wound care, clean the wound, update tetanus, watch for cellulitis. Do not attempt to “suck out” the venom. No indication for using a tourniquet. Extremities should be monitored for compartment syndrome. Limbs should be measured. Patients should receive IVF and may need pressors.

2.       Respiratory support: Patients with bites to the head and neck are at risk for airway compromise due to edema. Early intubation should be considered in these patients.

 

3.       Antivenom Therapy: There are two antivenoms approved, Crofab and Anavip. Crofab is the original, Anavip was just approved in 2015.

1. Criteria for administration of Crofab or Anavip– significant progression of swelling, abnormal test results (plt less than 100k or fibrinogen less than 100), altered vital signs or altered mental status.

2. Crofab is given as 6 vials, usually diluted into 1 L of NS and run over an hour. Repeat doses (2 vials) may be given if symptoms persist at 6, 12, and 18 hours. Patients should be monitored for allergic reactions.

3. Anavip is a newer antivenom. It is given as 10 vials, repeated Q1H PRN for initial control of local signs of envenomation. 4 vials are given as maintenance for symptom recurrence.

Both antivenoms are quite expensive. Crofab is $3400 per vial and Anavip is $1200 a vial. Patients with systemic symptoms and receiving antivenom should go to the ICU.

Buchanan JT, Thurman J. Crotalidae Envenomation. [Updated 2022 Oct 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551615/

Hessel MM, McAninch SA. Coral Snake Toxicity. [Updated 2023 Mar 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519031/

Spider Bites

The brown recluse spider, scientifically known as Loxosceles reclusa, is known for its venomous bite. This spider is found in southern US states.

1. Mechanism of Toxin: Sphingomyelinase D causes hemolysis and complement mediated erythrocyte destruction. There are multiple proteases that break down collagen, elastin, fibrinogen, etc and act synergistically with sphingomyelinase D to cause local tissue destruction

2. Clinical Features of Bites:

   • Course of bite: The bite is often painless or with minimal pain. There will be two small puncture wounds. This will become pale with the edges becoming red. Over the next few days, this turns into a blister with a central ulcer, followed by skin sloughing. Can take weeks for wound to heal.

   • Early Symptoms (2-8 hours):

     • Redness and swelling around the bite site

     • Mild to moderate pain and itching

   • Delayed Symptoms (12-36 hours):

     • Necrotic (dead) tissue formation, leading to an ulcer

     • Systemic symptoms like fever, chills, malaise, headache, nausea

   • Worsening complications:

     • DIC

     • Rhabdo

     • Kidney Failure

3. Evaluation: Lab tests should only be ordered in patients with systemic symptoms and fear of worsening complications. Should order CBC, CMP, CK, retic count, haptoglobin, LDH, PT/INR, D-dimer, fibrinogen.

4. Medical Management:

   • Local Wound Care: Primary management is local wound care. Clean the site with soap and water, apply a cold compress to reduce swelling, and elevated the affected site. Sphingomyelinase D also has reduced activity in lower temp, so ice packs are important! Patient should also receive tetanus prophylaxis!

   • Pain Management: NSAIDs

   • Wound Care for Necrotic Tissue: If wound is severe enough, may require eval for debridement and potential skin grafting (this is usually weeks later). Hyperbaric oxygen therapy can also be considered for severe cases.

   • Antibiotics: Only if concern for local cellulitis.

   • Systemic Treatments: Weak evidence for use of dapsone. There is slightly more evidence behind the use of corticosteroids for reducing the risk of AKI and rhabdo.

It's crucial to note that brown recluse spider bites are rare, and most cases resolve with local wound care.

Black widow spiders, known as Lactrodectus spp, are venomous arachnids found in various regions around the world. The venom they produce contains neurotoxins, primarily alpha-latrotoxin, which affects the nervous system. These spiders classically have the “red hourglass” marking on them.

1.       Mechanism of Toxin: The primary toxin in black widow spider venom is alpha-latrotoxin. It works by binding presynaptic neurons, creating calcium permeable channels in the lipid layers, causing an influx of calcium into the presynaptic cells. This leads to an excessive release of neurotransmitters. Primarily concerned with release of acetylcholine.

2.       Clinical Features of Bites:

• Course of bite: Bites are often initially characterized by severe local pain at the bite site. Very quickly patients will develop erythema and edema at site of bite

• Systemic Symptoms: As the venom spreads, systemic symptoms may develop, including muscle pain and cramps, abdominal pain, weakness, sweating, and nausea. Patients may experience autonomic nervous system effects such as increased blood pressure and heart rate.

• Worsening complications

  • Rhabdo

  • Myocarditis

  • A-fib

3.     Laboratory Tests: Lab values are generally nonspecific for black widow bites. Patients will tend to have elevated WBC, hematuria, and elevated liver enzymes. There are documented cases of rhabo and myocarditis from black widow bites, and there for kidney function and troponins can be checked if patients complain of systemic symptoms.

4.       Medical Management:

• Local Wound Care: Clean the site with soap and water. Patient should also receive tetanus prophylaxis!

• Pain Control: Analgesics, such as opioids or muscle relaxants, may be used to manage pain.

• Antivenom: In severe cases or when systemic symptoms are significant, antivenom may be administered. This can rapidly reverse the effects of the venom. It is horse derived, and may cause anaphylaxis.

• Observation: Patients may be observed for several hours to ensure symptoms do not worsen and to monitor for potential complications. Consider admission in children, patients with preexisting cardiac conditions, pregnant women, or for severe symptoms.
  
  It's important to note that while black widow spider bites can be painful and cause distressing symptoms, fatalities are rare.
  
   
  
  Anoka IA, Robb EL, Baker MB. Brown Recluse Spider Toxicity. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537045/
  
  Williams M, Sehgal N, Nappe TM. Black Widow Spider Toxicity. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499987/