Fish hook removal

Cite this article as:
Cliona Begley. Fish hook removal, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.29788

Sean, a 14-year-old boy, was out fishing with friends. While tidying away his gear, a used barbed fishhook became lodged in his second finger on his right (dominant) hand. Sean and his friends attempted to remove the hook but were unsuccessful. Sean feels otherwise well, has no long-term medical problems and is unsure when his last vaccinations were. 

Is this a common problem?

Depending on where your Emergency Department is situated, a child with a fisk hook lodged somewhere can be an exceedingly rare or pretty common presentation. Most hooks will be embedded superficially in fingers or feet and be easily removed by an easy-to-master technique. However, some hooks can become lodged in eyes/ eyelids or have penetrated deeper. These may warrant a surgical referral. Let’s have a look at how we can evaluate which fishhooks can be removed in the ED and which ones we might be more cautious about.

What type of hook are we dealing with?

There are many different types of hooks. They vary both in size and the number of hooks or barbs present. 

The most important thing for us to know as clinicians is whether the hook is barbed or not. 

Lots of different fish hooks
The anatomy of a fish hook

The most common type of hook has an eyelet at one end, a straight shank, and a curved belly that ends in a barbed point on the inner curve that points away from the hook’s tip as shown above.

Some fishhooks may be multi-hooked or have a lure (an artificial fishing bait) attached. These will need to be clipped from the main shank prior to removal. Some hooks will have multiple barbs along the shank. These hooks cause greater tissue damage. 

What should we be looking out for?

When evaluating a lodged fishhook and its suitability for removal in the Emergency Department, consider the following:-

Important aspects in the history:

  • Where the incident occurred i.e freshwater vs salt water?
  • Whether or not the hook has been used?
  • Vaccination status as they will require a tetanus booster if not up to date. 
  • History of immunocompromise and bleeding disorders.

Your examination should include:

  • Site and depth of penetration. Most hooks will lodge superficially in fingers or hands, and less frequently in feet, the face or the head. These can be safely removed in the ED. Subspecialty consultation should be obtained for fish hooks lodged in the eye or eyelid, vascular structures, the genital area or if there is clinical evidence of neurovascular compromise. Careful assessment of the depth of penetration and integrity of surrounding structures and joints is important.
  • Type of fishhook. See techniques below.
  • Wound. Assess for active bleeding or evidence of gross contamination that may need management in theatre.
Case courtesy of Dr Yair Glick, Radiopaedia.org. From the case rID: 73822

How are we going to get it out?

First off, good analgesia to manage the pain is paramount. Generally, local infiltrative anaesthesia is highly effective in older, cooperative patients. Younger children may require procedural sedation to facilitate this.

Next, think about the child’s tetanus status and give prophylaxis as indicated.

And thirdly, think carefully about your removal techniques. Five techniques of fishhook removal are described. Your choice of technique depends on: 

  • Type of hook
  • Depth of entrapped point
  • Body part involved

Regardless of the method used, all wounds should be cleaned and prepped prior to removal.   If the hook is multi-hooked or if there is a lure attached, clip off the end before you attempt removal to minimise tissue damage. The objective of each technique is to disengage the barb with as little tissue trauma as possible. Let’s take a look at the five techniques.

The back-out technique

The back-out technique can only be used with a barbless fishhook. Simply grasp the shank of the hook and back the hook out of the wound. 

Hook in finger
The problem

The push-through technique

This technique can be used for superficially embedded barbed hooks where the point of the hook is close to the skin. To avoid injury from the barb, you should always wear protective equipment. 

Cutting out the hook
The push through

The string method

The string technique can be used for single barbed hooks that are embedded in a body part that can be firmly secured so that it does not move during the procedure. It fails if the force isn’t sudden enough so don’t be afraid to give the string a good pull.

Pull the string to release the hook
The string method

The needle technique

This technique works well with larger hooks that are superficially embedded. A needle is used to cover the barb therefore the hook can be backed out the entry wound. It can be difficult and is only to be used once other techniques have failed. 

The needle acts as a barb guard
The needle technique

Cut it out

When all other techniques have failed, you may consider cutting out the hook. Under adequate anaesthesia, an incision is made along the body of the hook and the hook is removed. 

What about once the hook has been removed?

The name of the game here is to minimise the risk of infection. Firstly, thoroughly irrigate the wound with normal saline.

Should I give empiric antibiotics?

No clinical trial to date has addressed the need for empirical antibiotics in fishhook wounds. In general, empirical antibiotics are prescribed.

If the hook was not contaminated, empiric antibiotics for skin flora is recommended. Treat as if there might be uncomplicated cellulitis and follow local guidelines.

If the hook was contaminated, consider other pathogens including Aeromonas, Edwardsiella tarda, Vibrio vulnificus and Mycobacterium marimun. Use an oral first-generation cephalosporin or, in patients with acephalosporin allergy, oral clindamycin, plus an oral fluoroquinolone such as levofloxacin. If there is seawater exposure, add doxycycline to cover for Vibrio (although avoid in children under 8 as it causes teeth discolouration and enamel hypoplasia). If there was soil contamination or exposure to sewage-contaminated water, add metronidazole to cover for anaerobes, unless you are already using clindamycin.

Sean’s hooked was embedded superficially in the finger pulp, with no evidence of damage to deeper structures. It was removed with ease in the Emergency Department using the push-through technique. His wound was thoroughly cleaned and he was discharged with a prescription for prophylactic antibiotics. He was given a tetanus booster and educated on the signs and symptoms of wound infection. 

Selected references

Aiello LP, Iwamoto M, Guyer DR. Penetrating ocular fish-hook injuries. Surgical management and long-term visual outcome. Ophthalmology. 1992;99(6):862. 1630774

Malitz DI. Fish-hook injuries. Ophthalmology. 1993;100(1):3. 8433823

Su, E. Removal of a barbed fishhook. In: Illustrated Textbook of Pediatric Emergency and Critical Care Procedures, Diekema, RA, Fiser, DH, Selbst, SM (Eds), Mosby, St. Louis 1997. p.727

https://www.uptodate.com/contents/fish-hook-removal-techniques#H3

Foreign bodies

Cite this article as:
Becky Platt. Foreign bodies, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.25947

This post is based on a talk I gave for the London School of Paediatrics in June 2020, and will focus on foreign bodies in the nose and ear.  If you’d like to read about ingested foreign bodies, please read this, from Andrew Tagg.

Foreign bodies in the ear or nose

Children often present to the emergency department with something alien in their ear or nose. They’re usually in the pre-school age group and have been experimenting by sticking things in their various orifices. Most children can be found with a finger up their nose on a fairly regular basis, but sometimes other objects too. These can be among the more light-hearted of ED attendances, but only if you have some strategies to deal with them.

4-year-old George comes into your ED with his exasperated mother.  She explains that he’s been telling her he has a phone in his ear for the last 2 days. “Obviously he hasn’t”, she says, “but please would you just have a quick look so I can tell him to stop going on about it”. You have a quick look in his ear, and you see something blue in there.* How will you proceed?

General considerations to aid success

Preparation is key. This means preparing the child, and yourself, for the procedure.

Think of foreign body removal as a one-time offer. You’ll generally have only one good go at it, so preparation is everything. This means getting the right people involved, ideally, a play specialist or someone else whose only role is to distract and calm the child. Make sure they know what is going to happen if they are old enough to understand. If they are unable to keep still, position them appropriately on their parent’s lap or maybe wrapped in a blanket. Foreign body removal is generally not painful (or shouldn’t be) but for children who are able, nitrous oxide can be a useful aid for its anxiolytic properties in addition to distraction.

Prepare yourself. Make sure you use the right technique and equipment for the job. There are several options:

Kissing technique

This is a useful technique for removing FBs from the nose and works especially well for solid objects such as beads. Getting the parent on board with it and briefing them about the technique is key:

  • Sit the child sideways on the parent’s lap with one of the child’s arms tucked away under the parent’s arm
  • Brief the parent that you want them to cover the child’s mouth with their own while you occlude the unaffected nostril
  • Get the parent to deliver a short sharp breath and, hopefully, the FB will shoot out!

For parents who either can’t master the technique, or can’t face it, the same effect can be achieved with a bag-valve-mask: choose a mask that only covers the child’s mouth, and occlude the pop-off valve to increase the pressure. Ask a colleague to hold the mask and the unaffected nostril, while you squeeze the bag sharply.

Other useful tools and techniques

Head torch – this is a game-changer in the world of foreign body removal. It prevents you from having to try to hold a torch in your mouth while holding an ear in one hand and tool in the other.

Head torch

Yankauer suction – good for removing objects with a smooth surface e.g. beads, polystyrene balls. Warn the child it’ll be noisy and let them hear it before you start so they don’t jump away.

Syringe and water – good for items that will float or disintegrate e.g. tissue, play-doh, polystyrene beads. Add a cut-down NG tube on the end to make a smaller nozzle. Fill with warm water (for comfort) and irrigate generously. 

Jobson Horne probe – useful to get behind objects in the ear canal that won’t come out with suction. In this case, it will only work if there’s a little gap and you can actually get behind it.

Wax hook – can be used to get behind foreign bodies, as above, or to hook into softer objects such as bits of tissue or peas. Make sure you don’t leave some behind with this method.

Tools for removing foreign bodies from ears and noses

Crocodile forceps – helpful with small or softer objects or those with an uneven surface where there’s something to grab.  

TOP TIP: magnetize the shaft to make it easier to pick up metal FBs

Magnets – can be used by rubbing them down the side of the nostril to work a foreign body down and out.

TOP TIP: the magnets on name badges are often useful for this if you don’t have a store of magnets specifically for the purpose.

Cotton bud and glue – can be used to remove foreign bodies from the ear canal if they’re difficult to get behind or to grab.  Apply a drop of whatever tissue adhesive you use to the end of a cotton bud and hold it on the offending item for 30 seconds or so then pull out.  This requires a steady hand and a reasonably still child. Be aware that this method can lead to adherence of the offending item to the ear canal.

Foley catheter – pass it behind a foreign body in either the nose or ear, inflate the balloon and then pull out, bringing the piece of corn with it.

If at first, you don’t succeed… stop

Complications can arise from failed attempts at removal, especially those involving the ear canal. These can range from pain, bleeding, distress, and the loss of trust to rare, but severe, complications including middle ear damage, hearing loss, vertigo, facial nerve paralysis and meningitis (Dance et al., 2009). If an attempt isn’t going well, stop, re-group, and consider the options. It may be that referral or a different approach is required.

Or maybe, don’t even start

If there is minimal chance of success, either because the FB is deep, impacted, or ungrabbable, or the child is unable to co-operate for whatever reason, think twice before starting. It may be better to bring them back when you have play specialist support or to refer to ENT for specialist assistance.

You involve the play specialist and prepare George for removal of the foreign body in his ear.  Wearing your headtorch, you gently pull on his pinna and gently insert a pair of crocodile forceps into his ear canal and pull out… a teeny tiny toy phone!  Vindicated, George squares up to his mum: “I told you!”.

*This is a true story (anonymized) from a long time ago, and one of my favourite ED presentations ever!

Selected references

Chan, T. C., Ufberg, J., Harrigan, R. A., & Vilke, G. M. (2004). Nasal foreign body removal. Journal of Emergency Medicine, 26(4), 441–445. https://doi.org/10.1016/j.jemermed.2003.12.024

Dance, D., Riley, M., & Ludemann, J. P. (2009). Removal of ear canal foreign bodies in children: What can go wrong and when to refer. British Columbia Medical Journal, 51(1), 20–24. https://www.bcmj.org/articles/removal-ear-canal-foreign-bodies-children-what-can-go-wrong-and-when-refer

Don’t Forget The Lego

Cite this article as:
Team DFTB. Don’t Forget The Lego, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17375

It might have escaped your notice but the team at DFTB recently had a paper published by the Journal of Paediatrics and Child Health that has garnered a lot of interest.

Tagg, A. , Roland, D. , Leo, G. S.Y., Knight, K. , Goldstein, H. , Davis, T. , DFTB, (2018), Everything is awesome: Don’t forget the Lego. J Paediatr Child Health. doi:10.1111/jpc.14309

We are sure you have questions. Lots of questions. So we thought we should answer them for you in the best way we know how.

What pressing scientific question did you ask?

We know that coins are the most commonly swallowed foreign object in the paediatric population and there is a lot of data surrounding transit time. The second most commonly swallowed objects are small toys but there is very little data out there. We wanted to know how long it would take for a small piece of plastic toy, in this case a Lego head, to pass through.

How on earth did you come up with the idea?

In one of our regular editorial meetings we were discussing some of our upcoming publications and musing how we could do something a little lighter, akin to the great Peppa Pig paper in last years Christmas BMJ. And then Andy Tagg said, “I’ve got this idea but you might think it a bit strange.” Within a short space of time we had an international team of researchers literally chomping at the bit to undertake the study.

Did you really swallow those poor heads?

Of course we did! Do you want proof?

Then what happened?

We waited to see what would happen. We all know corn kernels can whip through the colon in seemingly no time at all, but what about a little yellow piece of plastic? There was really only one way to find out.

And you searched through your own poo to find them? How?

As with any piece of research it is important to have a robust search strategy in place prior to commencement. A variety of techniques were tried – using a bag and squashing, tongue depressors and gloves, chopsticks – no turd was left unturned. And although we only used a very small sample size the fact that one of our heads went missing suggest that you really shouldn’t worry if you can’t find it.

What happened to the missing head?

Who knows? Perhaps one day many years from now, a gastroenterologist performing a colonoscopy will find it staring back at him.

But what about Ben Lawton? Where was he when all this was going on?

Don’t Forget the Bubbles was founded by four curious doctors – Tessa Davis, Andy Tagg, Henry Goldstein and Ben Lawton. Unfortunately Ben was travelling at the time we undertook the study and we didn’t think searching through his colonic contents in an aeroplane toilet was exactly fair.

And then you kept it quiet, right?

It can take an average of 17 years for science to go from benchside to bedside. Leveraging social media we managed to go from online publication on a Thursday evening to global saturation by Saturday evening.

By Saturday morning Damian Roland was speaking on Canadian radio and the DFTB group made Forbes, ars technica, and the BBC World Service by the afternoon.

But surely this isn’t hard science?

Of course it’s not, it’s a bit of fun in the run up to Xmas.

With such a small sample size it is important that you don’t extrapolate the data to the entire population of Lego swallowers. Anecdata from Twitter suggests that a large number of people accidentally ingested bits of Lego throughout their life with no adverse effects*.

It is also worth noting that most people who swallow Lego are children, not fully grown adults. Data that is applicable to the adult population may well not be applicable to children.

For a more scientific approach to ingested foreign bodies in children then take a look at these two papers.

Yeh HY, Chao HC, Chen SY, Chen CC, Lai MW. Analysis of Radiopaque Gastrointestinal Foreign Bodies Expelled by Spontaneous Passage in Children: A 15-Year Single-Center Study. Frontiers in pediatrics. 2018;6:172.

Macgregor D, Ferguson J. Foreign body ingestion in children: an audit of transit time. Emergency Medicine Journal. 1998 Nov 1;15(6):371-3.

You may also enjoy exploring the following posts about foreign bodies on DFTB:

Andy’s blog post on Foreign Body Ingestion

Chantal McGrath’s DFTB17 talk Batteries Not Included on button battery ingestion

A case study by Loren on ‘the magic coin’ 

What’s next for the group?

Whilst this may be the pinnacle of our publishing careers we hope we have not peaked too early. Next up is finalizing all the details for our upcoming conference in London – www.dftb19.com, and then? Who knows?

*Please do not try this at home.

DFTB in the papers

Ars Technica

Forbes

BBC World Service

CBC Radio Canada – As it happens

10 Daily

Herald Sun

Problems with ear piercing

Cite this article as:
Andrew Tagg. Problems with ear piercing, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3374

Krystal is seven going on seventeen and is brought in by her mother because she is unable to take her earrings out.  She had her ears pierced a week ago..

 

Bottom Line

  • Infection due to poor hygiene is the most common complication of ear piercings
  • The mainstay of treatment is removal of the foreign body not antibiotics
  • Infection (often with Pseudomonas spp.) is more likely in high cartilage piercings

 

What are the usual methods used in high street ear piercing?

Most high street piercers (as opposed to specialty piercing/tattooists) use a gun that fires a blunt stud through the lobe.  This is then attached to a butterfly to keep the earring in place. Professional piercers use a hollow needle to form a track for the stud.

 

What are the potential complications?

Early infection is common especially in children who may not be as fastidious as teenagers with hygiene.  Lobe piercings may become infected leading to oedema and swelling around the retaining butterfly.  Higher piercings through the cartilage are at risk from perichondritis.  Both may lead to later piercing-related keloid formation.

Nickel alloy piercings can lead to contact dermatitis.

A piercing is also a great handle for bullies to grab and rip out.

Sounds like Krystal has a retained butterfly, how do you go about releasing it?

The technique is essentially the same no matter what the age.  The challenge is providing adequate pain relief and/or sedation to an inflamed ear.  Younger children respond well to topical EMLA with adjunctive nitrous, whereas older children may need only need some EMLA and ice.  Very occasionally true procedural sedation is required.

Using sterile technique identify the point where the back of the butterfly is nearest the surface of the skin on the back of the lobe and make a small nick.  Then push on the front of the lobe to expose the butterfly, like shelling a pea.  You should then be able to remove the backing without difficulty.  There may be a small amount of bleeding that can be covered with a sticking plaster.

Addendum 20/4/2019

Thanks to @babydocmacski for this suggestion

 

What is perichondritis?

High piercings can lead to infection of the cartilage and overlying soft tissue with possible disfiguring abscess formation.  The commonest organisms involved are Pseudomonas  and Staph. aureus.

 

How do you treat it?

They may require IV anti-pseudomonal antibiotics (such as piperacillin/tazobactam) as well as the removal of the foreign body.

 

What advice would you give Krystal (and her parents) about getting her ears pierced again?

She should wait until the wound has healed and choose an alternative site, ideally done by a professional piercer and be meticulous when it comes to hygiene.

 

Outcome

Krystal screams when you try to remove the butterfly under nitrous so you elect to perform procedural sedation using intravenous ketamine and EMLA.  Whilst adequately sedated and no longer wriggling, you manage to pop the butterfly out without further fuss.

 

Selected references

“High” ear piercing and the rising incidence of perichondritis of the pinna Junaid Hanif, Adam Frosh, C Marnane, K Ghufoor, R Rivron, G Sandhu BMJ. 2001 April 14; 322(7291): 906–907

Fijałkowska M, Pisera P, Kasielska A, Antoszewski B. Should we say NO to body piercing in children? Complications after ear piercing in children. Int J Dermatol. 2011 Apr;50(4):467-9

Timm N, Iyer S. Embedded earrings in children. Pediatr Emerg Care. 2008 Jan;24(1):31-3