Kids love to explore their worlds. That exploration, especially when combined with immature decision making and slow reflexes, can lead to foreign bodies of all sorts becoming lodged in body parts of all kinds. Appropriately, previous Ped EM Morsels have discussed several foreign body topics (ex, Aspirated FB, Ear FB, Delayed Dx of Aspirated FB, Button Battery FB, Nasal FB).   There is another type of foreign body that can be particularly challenging to deal with: The Fishhook.

Anglers are Awesome, but Fishhooks are Frustrating

• We are all aware of the benefit of “teaching a man to fish,” (you feed him for a lifetime) but teaching someone how to remove a fishhook is just as valuable!
• Fishhooks are perfectly designed to penetrate flesh and remain in place.
  • The distal point penetrates efficiently.
  • The barb locks it in place.

• Fishhooks often become embedded within areas that have delicate and sensitive structures:
  • Hands
  • Face / Scalp
  • Eyelid [Subramaniam, 2015, Deramo, 1999]
  • Eyeball
  • Tongue [Eley, 2010]
  • Pharynx
• Removal of an embedded fishhook is more challenging when it is in these sensitive regions.
  • The fishhook puts local structures at risk of injury.
  • The process of removing it also puts the regional tissue at risk.

Fishhook Foreign Body: Initial Evaluation

• History
  • Not all hooks are the same… how many barbs does this one have?
    • The patient, if an angler, may know.
    • An X-ray may be helpful to determine this. Can also evaluate local structures.

• Local structures
  • Refrain from yanking on the fishhook until you have contemplated potential involvement of local structures.
  • Are tendons, nerves, or blood vessels involved?
  • Bedside Ultrasound may be of benefit to help define depth and local structure involvement.

• Pain management – Don’t Be Cruel!
  • Appreciate the child’s apprehension and pain before you do any manipulation.
  • By making them comfortable first, you may even be able to avoid procedural sedation (an ounce of prevention, beats a pound of therapy).
    • Intranasal analgesics and anxiolytics
    • Nitrous Oxide
    • Topical
    • Local block
    • Regional block

• Update tetanus status
  • Last week we mentioned vaccinations in the ED… here is another opportunity!

Fishhook Foreign Body: Removal Techniques

• As with any procedure, knowing several methods can help you deal with the wide variety of variables that may occur.
• Before proceeding with any tactic, consider patient comfort, position, and safety.

• Since it is the barb that is causing the issue, it helps to think of how to neutralize its effect.
• The below are nicely outlined in multiple references, including [Subramaniam, 2015, Prats, 2013].

• DISENGAGE THE BARB
  • Downward pressure on the shank can help disengage the barb from the tissue track.
  • For superficial fishhook and the barb is small:
    • May be able to remove it by reversing through its path.
    • Least likely to work, but worth a single attempt sometimes.
  • For more deeply embedded or larger barbed fishhooks:
    • Wrap a large caliber suture around the distal curve.
    • Stabilize surrounding skin.
    • While depressing shank, yank the string parallel to the line of the shank.
      • Useful when sensitive structures are not involved.

• COVER THE BARB
  • An ~18-gauge can be used to cover and disengaged the barb.
  • Technically, this is challenging, as it requires accurate location of the barb in 3 dimensions. Easier to do with superficial fishhooks.
    • Advance the needle parallel to the shank, along the entry wound.
    • The bevel of the needle should face the barb and advanced until the barb is sheathed within the needle.
    • Once the needle covers the barb, both needle and fishhook are reversed through the wound opening together.

• CUT THE BARB
  • If the fishhook has passed completely through tissue and:
    • The barbed end is more accessible,
      • Cut the barbed end.
      • Reverse the remaining shank back out of the entry wound.
    • The shank is more accessible,
      • Cut the shank end.
      • Grab the barbed end and remove through the exit wound.
    • If the fishhook has not passed completely through the tissue:
      • Use needle drivers to advance the fishhook through the skin.
      • Choose to cut either the barbed end or the shank as above.

• EXCISE THE BARB
  • For a deeply embedded fishhook or one adjacent to very sensitive structures, creating a new path to remove it may be best option.
  • May require specialist involvement (ex, orthopaedist, ophthalmologist). [Deramo, 1999]

Fishhook Foreign Body Wound Care

• Irrigate
• Consider other retained foreign bodies.
• Local Wound Care with topical antibiotics
• Empiric systemic antibiotics are not routinely required in the otherwise healthy patient.

References