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/
3) https://www.tampaemergencymedicine.org/blog/fish-hook-removal
5) https://www.emrap.org/episode/ucprocedures/ucproceduresfishhookremoval
6) https://www.emrap.org/episode/fishhookremoval1/fishhookremoval1
7) https://www.emrap.org/episode/fishhookremoval/fishhookremoval