POTD: Fishhook Injury

Kelsey Clayman · November 19, 2024 · Foreign Body, Environmental

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

POTD: Bringing a needle to a knife fight

Freddi Tran · November 15, 2024 · Airway, Pediatrics

Hello friends,

For my final clinical content based POTD, I wanted to summarize the steps for a nightmare event: the pediatric can’t intubate, can’t oxygenate scenario.

Resus residents, do you ever find yourself just glossing over the small bag in the corner of the bottom drawer of the airway cart when you do your daily check? The one labeled with the piece of tape that says “jet insufflation”? Maybe in the back of your head you have a vague idea that it’s supposed to be used for a needle cric in pediatric patients below 8 years old. But that’ll probably never happen right? Well, I’m here to tell you…..you probably are right. But that doesn’t mean that we shouldn’t be prepared for it.

I remember early resus year when I would check that the things on the check list were in that bag, but not actually have the context for how it all pieced together. It wasn't until PGY-2 procedure day when me and my co-residents in our group realized what a blind spot it had been for us. What are these random small syringes with the top off? Why is there the top of an ETT just out and about in here? Well, after reviewing the steps for the procedure, hopefully you can visualize how it all comes together.

Steps

1. Prep and drape while locating the cricothyroid membrane.

2. Pierce the membrane with the 14G angiocath directed 30-45 degree caudally.

3. Advance catheter over needle, hub to skin, and remove needle.

4. Attach a 7-0 ETT adaptor to top of a 3mL syringe with plunger taken out and attach this apparatus to the catheter.

5. Attach a BVM to ETT adaptor.

6. Take a deep breath (but don’t forget to also give your patient one), you did it.

It’s a relatively simple procedure, just with insanely high stakes.

Because I’m very much a visual learner:

Here’s a quick 1:52 min video: https://www.youtube.com/watch?v=F_PV7N2c2pQ. Note how the video does it is probably slightly different than how we would with our own makeshift kit here. Sorry for the potato quality but it’s short and gets the point across.

And lastly, I wanted to summarize a recent article written in June (the First10EM link below) that actually advocates doing a surgical approach with a scalpel and not going down the needle cric route for kids like what is traditionally taught to us. The author was also featured on this week’s episode of EMRAP going over this topic. Basically multiple professional societies have come out with contradictory guidelines over the use of needle vs surgical cric, which is not helpful. Data is super limited because of the rarity of this event in this population. Pediatric case reports seem to demonstrate a lack of success of the needle approach as the first line and that complications are to be expected even when the airway is established. This is seen again and again in adult studies as well.

The author then advocates that having the peds surgical cric approach in your toolbox is the best guarantee of achieving a definitive airway in this scenario with the least complications.

In children less than eight years old, the cricoid membrane may be too small so the horizontal incision step is discarded. There is also a higher risk of transecting the entire trachea with the horizontal incision. Instead in the peds surgical approach, you would just do a vertical cut through the trachea (though no more than 2 tracheal rings as this can make repair afterwards more difficult).

Would love to know what other peds providers think about this stance. It does seem like it is branching a little bit farther than what we’re comfortable with, but this is where the art of medicine comes in because the paucity of data out there.

References

https://www.ncbi.nlm.nih.gov/books/NBK537350/

https://first10em.com/the-pediatric-cant-intubate-cant-oxygenate-scenario-use-a-knife/

https://www.tamingthesru.com/blog/acmc/needle-cricothyrotomy

Breathe easy friends!

POTD: Shock to the heart (and you're to blame)

Freddi Tran · November 15, 2024 · Cardiovascular, EKG

Hello folks,

Today’s POTD will be a quick overview of implantable cardioverter-defibrillators (ICDs) and their common complications.

Why do patients have an ICD in place?

Secondary prevention in previous episodes of unstable VT or VF.

Primary prevention if pt has hx of severe heart failure or underlying congenital arrhythmias.

Exact indications listed below:

Hx of MI within last 40 days with LVEF of <30%, NYHA Class II or III heart failure with an LVEF <35%, underlying disorders which place them at high risk of unstable VT or VF such as congenital long QT syndrome, HOCM, Brugada, ARVD

What does an ICD do?

Note that all ICDs are also pacemakers, but the reverse is not true (pacemakers do not have defibrillator/shocking functionalities).

Anti-tachycardia function: If the patient is tachycardic above a pre-set range (usually 150-220) the ICD will compare QRS morphology to a known sinus beat and if determined to be different, will deliver a series of paced beats at a rate slightly faster than the native rate to break the re-entrant cycle.

Defibrillation in response to sensed VT or VF

What can go wrong with ICDs?

In short, problems with ICDs/pacemakers come down to a failure of sensing or a failure of pacing.

Pacing malfunction:

Failure to pace: pacemaker doesn’t deliver a stimulus at all, resulting in return of the underlying rhythm.

Failure to capture: pacemaker delivers a stimulus, but the stimulus does not result in depolarization. EKG will show pacer spikes that are not followed by P waves or QRS complexes.

Sensing malfunction:

Failure of sensing: pacemaker fails to sense normal cardiac activity so an impulse is delivered inappropriately. EKG will show intermittent pacer spikes.

Oversensing: pacemaker identifies external signals such as from skeletal muscle contraction as “appropriate” and will not send an impulse when one is required.

Other problems:

Pacemaker mediated tachycardia: formation of a re-entrant circuit from retrograde p waves being sensed as native atrial activity, causing inappropriate tachycardia. This tachycardia does not exceed the programmed upper limit of the ICD.

Twiddler syndrome: accidental or intentional manipulation of the pulse generator resulting in dislodgement of pacing leads resulting in sx such as diaphragmatic or brachial plexus pacing. Will manifest as arm twitching or uncontrollable hiccups depending on where lead has migrated.

Miscellaneous pearls

Because most ICDs have only a lead in the RV, a LBBB pattern is expected on EKG; new RBBB pattern/axis deviation may indicate lead migration/dysfunction.
If you need to externally cardiovert or defibrillate, place pads at least 8cm away from device in anterior-posterior orientation.
Placing a magnet over the device will remove the defibrillator function of an ICD, but pacing function will be kept. This will be helpful in the setting of inappropriate shocks. Kept in charge nurse desk on north side usually!
Every patient should carry a pocket card indicating the manufacturer of their ICD, but it can also be ID’d by CXR and using an app called Pacemaker!
We’re lucky we have electrophysiology as a consult service here at Maimo that can interrogate a device for us, but each company has on-call representatives that will come interrogate a device 24/7.
- Medtronic Inc. (1-800-328-2518)
- St. Jude Medical Inc.(1-800-722-3774)
- Boston Scientific Inc. (1-800-227-3422)