lostatsea
03-21-2009, 12:45 PM
How many times have we all been injured while fishing? Wether it be gashes in legs, or sinkers hitting our heads or hooks in body parts it is the mark of a fisherman.
I saw this guide to removing fish hooks so decided to post it.
After the read, how about taking a minute and list your past injuries.
Management of Fishhook Injuries.
Across the country, recreational fishing is a popular leisure activity. In several states, fishing is the number one outdoor sport with one in four Americans participating at least once each year. In places with crowded fishing conditions, and especially in areas where fly-fishing is popular, fishhook injuries are not uncommon due to the volume of anglers. In rural or remote settings, the likelihood of a fishhook injury presenting to a general practitioner rather than an emergency department is going to be increased by simple geography. As an avid angler I will most likely practice in an area with productive fishing waters whether remote, or crowded. Since the muskie fish is my species of choice to pursue, it puts me on bodies of water where fishermen are using the largest and most dangerous fishing equipment seen on fresh water lakes. With hooks exceeding two inches on average lures, hook extraction becomes slightly more challenging. (See figure 1 (http://www.kevinwakeman.com/fam/hookout.htm#F)) So it has been my goal to review the data and case reports that are available, and to determine the most reasonable course of action when presented with a fishhook impaled in a patient, friend, family member, or even myself.
Figure 1. (Hooks are shown actual size)
http://www.kevinwakeman.com/_borders/Image6.gifhttp://www.kevinwakeman.com/_borders/Image7.gif
During peak fishing periods in spring and summer wounded anglers may present with fishhooks lodged almost anywhere. In most cases however, the fishhooks are lodged in one of the fisherman's fingers. If you are practicing in an area where fly-fishing is commonplace, then the head will be a close second behind the finger on the list of body areas most commonly hooked. While data on fishhook injuries is sparse, probably because of the relatively minor size of the average injury, some emergency departments in heavily fished areas see more than 600 cases per year. (1) This article will discuss techniques for fishhook removal from non-vital structures, pathogens common to fresh water injuries, and proper antibiotic prophylaxis. This discussion only applies to fishhooks embedded in areas where a primary care physician would normally perform routine skin lesion excisions. Fishhook removal from areas such as the eyes, anterior neck, and in close approximation to known neurovascular bundles should be performed by the appropriate specialist. (1)
Most clinicians have heard of the "push through and cut off" technique for fishhook removal. Standard texts for emergency medicine describe removing hooks by gripping the hook with a needle driver and advancing the hook through the tissue until the barb end of the hook penetrates through the skin at a separate location. The barb end of the hook is then cut off with a wire cutter, and the remainder of the hook is backed out through the entry site. (2, 3) (See figure 2 (http://www.kevinwakeman.com/fam/hookout.htm#Fi)) The main disadvantages of this method include damaging uninjured tissue and extending the contaminated field. This technique is also limited in its usefulness if the hook tip lies in deeper structures, which prevent advancing the hook (i.e. bone, ligament, tendon ), or if advancing the hook would too closely approach a known neurovascular bundle. (1)
Figure 2
Injury http://www.kevinwakeman.com/fam/Image10_small.gif (http://www.kevinwakeman.com/_borders/Image10.gif)
Advance hook http://www.kevinwakeman.com/fam/Image8_small.gif (http://www.kevinwakeman.com/_borders/Image8.gif)
Remove barb http://www.kevinwakeman.com/fam/Image9_small.gif (http://www.kevinwakeman.com/_borders/Image9.gif)
Back out hook http://www.kevinwakeman.com/fam/Image11_small.gif (http://www.kevinwakeman.com/_borders/Image11.gif)
A less well-known technique for removing fishhooks was first described in 1961 by Dr. Cooke. (4) He had seen commercial fishermen in New Zealand remove hooks from themselves using only a piece of string. Nobody knows how long they have been using this technique, or who should be credited for its invention. But as Cooke pointed out, "fishers have long used the string flick technique because it allows them to remove the hook, dip the finger in the sea, and carry on fishing within a minute." (4 ) Dr. Cooke, a general practitioner from south Australia, published his account in an article titled, "How to remove fish hooks with a bit of string." Since then, it has been described multiple times with a few slight variations. (5,6,7,8) The basic principle is as follows (see figure 3 (http://www.kevinwakeman.com/fam/hookout.htm#Fig)):
A piece of strong string/suture is tied to the bend of the hook.
The shank of the hook is depressed to disengage the barb.
While the shank is being depressed, the string is given a hard, sharp, decisive jerk in the direction in which the hook entered the skin. This extracts the hook along the path of entry.
Figure 3
A http://www.kevinwakeman.com/fam/Image14_small.gif (http://www.kevinwakeman.com/_borders/Image14.gif)
B http://www.kevinwakeman.com/fam/Image12_small.gif (http://www.kevinwakeman.com/_borders/Image12.gif)
C http://www.kevinwakeman.com/fam/Image13_small.gif (http://www.kevinwakeman.com/_borders/Image13.gif)
Since its initial description, this string technique has become the preferred method of fishhook removal for many emergency medicine and family physicians. (5,6,9) Some have proclaimed that all you need is a length of string and nerves of steel, deferring the use of local anesthetic. Several authors state that when the technique is performed correctly, it is "painless". (10) However, most authors do recommend the use of local anesthetics. (1,2,3,5,8, etc.) I would assert that for the uninitiated physician, the anesthetic will put him at ease as much as the patient.
Several clinicians report uniform success using the string technique. One author noted that of the 32 fishhook injuries that presented to the Queen Elizabeth Hospital in south Australia in a one-year period, 26 of the 32 were successfully removed with the string method. The author presumed that the 6 failures were due to a "half-hearted" attempt on the part of the attempting doctor. (12)
The major benefits of the string removal method include minimizing the size of the wound, and limiting the contaminated field. (1,12)
Obviously the traditional method creates additional trauma to the tissues as the hook is advanced through the skin to penetrate at a second location. (13) The string method usually does not enlarge the wound track or extend the point of entry if the barb of the hook has been properly disengaged with downward pressure on the shank of the hook. (12) Another benefit is the option of quickly removing a fishhook without anesthetic if you find yourself presented with an impaled person while minding your own business at a park or a lake. Dr. S. S. David of south Australia goes so far as to tout that this method has the benefit of not ruining the fisherman’s favorite lure by cutting off a barb. (12) Though cutting away the excess hooks (those not embedded) from a lure before yanking on it with a string, seems prudent to myself and others. (11)
Once the fishhook has been successfully removed, by either method, the question of infection control arises. Obviously, any wound should be thoroughly irrigated and cleaned. However, it is not an uncommon practice for fishermen to wash superficial injuries in the waters they are fishing. (14) Dr. Cooke even described this practice. (4) Most fishermen are unaware of the potentially serious pathogens, which inhabit nearly all bodies of fresh water.
The organisms responsible for the most complications are the Aeromonas species. While infections with these organisms are rare in otherwise healthy persons, they are common pathogens in otherwise healthy persons that have wounds which are exposed to fresh water, whether exposed directly or via a contaminated fishhook. (14,15,16) Aeromonas hydrophilia is a motile, facultative anaerobic gram negative rod, which is indigenous to fresh and brackish waters. It is usually resistant to ampicillin and first and second-generation cephalosporins (14,17,18).
It is usually treated with fluoroquinolones, most commonly ciprofloxacin. (14) Alternative drugs include trimethoprim-sulfamethoxazole, aztreonam, and third generation cephalosporins +/- aminoglycosides. (14) Commonly used oral cephalosporins, such as cephalexin, have no activity against Aeromonas and are insufficient for fresh water exposed wounds. (19,20)
Infections caused by Aeromonas hydrophilia can be invasive and are frequently rapidly progressive. In a report of 23 confirmed cases of Aeromonas wound infections following exposure to fresh water, 39% involved fascia, tendon, muscle, bone, or joints. (17)
Case reports have documented numerous severe infections due to Aeromonas after a seemingly trivial fishhook injury. The majority of these cases involve persons with comorbid conditions which compromise the immune or vascular systems. One case involved a 59-year-old diabetic man who sustained a very small fishhook puncture on his forearm. He removed the hook by himself and washed the wound in the lake where he was fishing. Within 36 hours he had developed septic shock.
Cultures eventually grew Aeromonas hydrophilia. Unfortunately, even after starting intravenous ciprofloxacin and ceftazidime, the infection progressed, resulting in formation of necrotizing myositis requiring surgical debridement, followed by eventual amputation of his limb above the elbow. While this is an extreme example, it does demonstrate the serious potential for fresh water exposed wounds in patients with immune or vascular compromise. These patients should always receive prophylactic antibiotics with Aeromonas coverage. (17,18) Even patients without comorbid conditions or relative compromise, should be closely examined and treated at the first sign or symptom of infection with suitable Aeromonas coverage. (14,19)
While there are no studies comparing different methods of fishhook removal, and no studies examining infection rates or pathogens following fishhook injury, and the only available literature consists of case reports and clinical anecdotes, I think that a reasonable approach to this problem can be synthesized. A little knowledge and some common sense should prevent a fishhook injury from becoming serious.
In conclusion, this will be my approach when next presented with a person impaled by a fishhook: (Assuming that the hook does not too closely approximate a vital structure or known neurovascular bundle.) I will clean and anesthetize the area. I will first employ the string method as described above, in hopes of avoiding extending the wound and field of contamination. If this method proves unsuccessful, I would resort to the push-through-and-cut technique.
http://www.kevinwakeman.com/fam/hookout.htm
I saw this guide to removing fish hooks so decided to post it.
After the read, how about taking a minute and list your past injuries.
Management of Fishhook Injuries.
Across the country, recreational fishing is a popular leisure activity. In several states, fishing is the number one outdoor sport with one in four Americans participating at least once each year. In places with crowded fishing conditions, and especially in areas where fly-fishing is popular, fishhook injuries are not uncommon due to the volume of anglers. In rural or remote settings, the likelihood of a fishhook injury presenting to a general practitioner rather than an emergency department is going to be increased by simple geography. As an avid angler I will most likely practice in an area with productive fishing waters whether remote, or crowded. Since the muskie fish is my species of choice to pursue, it puts me on bodies of water where fishermen are using the largest and most dangerous fishing equipment seen on fresh water lakes. With hooks exceeding two inches on average lures, hook extraction becomes slightly more challenging. (See figure 1 (http://www.kevinwakeman.com/fam/hookout.htm#F)) So it has been my goal to review the data and case reports that are available, and to determine the most reasonable course of action when presented with a fishhook impaled in a patient, friend, family member, or even myself.
Figure 1. (Hooks are shown actual size)
http://www.kevinwakeman.com/_borders/Image6.gifhttp://www.kevinwakeman.com/_borders/Image7.gif
During peak fishing periods in spring and summer wounded anglers may present with fishhooks lodged almost anywhere. In most cases however, the fishhooks are lodged in one of the fisherman's fingers. If you are practicing in an area where fly-fishing is commonplace, then the head will be a close second behind the finger on the list of body areas most commonly hooked. While data on fishhook injuries is sparse, probably because of the relatively minor size of the average injury, some emergency departments in heavily fished areas see more than 600 cases per year. (1) This article will discuss techniques for fishhook removal from non-vital structures, pathogens common to fresh water injuries, and proper antibiotic prophylaxis. This discussion only applies to fishhooks embedded in areas where a primary care physician would normally perform routine skin lesion excisions. Fishhook removal from areas such as the eyes, anterior neck, and in close approximation to known neurovascular bundles should be performed by the appropriate specialist. (1)
Most clinicians have heard of the "push through and cut off" technique for fishhook removal. Standard texts for emergency medicine describe removing hooks by gripping the hook with a needle driver and advancing the hook through the tissue until the barb end of the hook penetrates through the skin at a separate location. The barb end of the hook is then cut off with a wire cutter, and the remainder of the hook is backed out through the entry site. (2, 3) (See figure 2 (http://www.kevinwakeman.com/fam/hookout.htm#Fi)) The main disadvantages of this method include damaging uninjured tissue and extending the contaminated field. This technique is also limited in its usefulness if the hook tip lies in deeper structures, which prevent advancing the hook (i.e. bone, ligament, tendon ), or if advancing the hook would too closely approach a known neurovascular bundle. (1)
Figure 2
Injury http://www.kevinwakeman.com/fam/Image10_small.gif (http://www.kevinwakeman.com/_borders/Image10.gif)
Advance hook http://www.kevinwakeman.com/fam/Image8_small.gif (http://www.kevinwakeman.com/_borders/Image8.gif)
Remove barb http://www.kevinwakeman.com/fam/Image9_small.gif (http://www.kevinwakeman.com/_borders/Image9.gif)
Back out hook http://www.kevinwakeman.com/fam/Image11_small.gif (http://www.kevinwakeman.com/_borders/Image11.gif)
A less well-known technique for removing fishhooks was first described in 1961 by Dr. Cooke. (4) He had seen commercial fishermen in New Zealand remove hooks from themselves using only a piece of string. Nobody knows how long they have been using this technique, or who should be credited for its invention. But as Cooke pointed out, "fishers have long used the string flick technique because it allows them to remove the hook, dip the finger in the sea, and carry on fishing within a minute." (4 ) Dr. Cooke, a general practitioner from south Australia, published his account in an article titled, "How to remove fish hooks with a bit of string." Since then, it has been described multiple times with a few slight variations. (5,6,7,8) The basic principle is as follows (see figure 3 (http://www.kevinwakeman.com/fam/hookout.htm#Fig)):
A piece of strong string/suture is tied to the bend of the hook.
The shank of the hook is depressed to disengage the barb.
While the shank is being depressed, the string is given a hard, sharp, decisive jerk in the direction in which the hook entered the skin. This extracts the hook along the path of entry.
Figure 3
A http://www.kevinwakeman.com/fam/Image14_small.gif (http://www.kevinwakeman.com/_borders/Image14.gif)
B http://www.kevinwakeman.com/fam/Image12_small.gif (http://www.kevinwakeman.com/_borders/Image12.gif)
C http://www.kevinwakeman.com/fam/Image13_small.gif (http://www.kevinwakeman.com/_borders/Image13.gif)
Since its initial description, this string technique has become the preferred method of fishhook removal for many emergency medicine and family physicians. (5,6,9) Some have proclaimed that all you need is a length of string and nerves of steel, deferring the use of local anesthetic. Several authors state that when the technique is performed correctly, it is "painless". (10) However, most authors do recommend the use of local anesthetics. (1,2,3,5,8, etc.) I would assert that for the uninitiated physician, the anesthetic will put him at ease as much as the patient.
Several clinicians report uniform success using the string technique. One author noted that of the 32 fishhook injuries that presented to the Queen Elizabeth Hospital in south Australia in a one-year period, 26 of the 32 were successfully removed with the string method. The author presumed that the 6 failures were due to a "half-hearted" attempt on the part of the attempting doctor. (12)
The major benefits of the string removal method include minimizing the size of the wound, and limiting the contaminated field. (1,12)
Obviously the traditional method creates additional trauma to the tissues as the hook is advanced through the skin to penetrate at a second location. (13) The string method usually does not enlarge the wound track or extend the point of entry if the barb of the hook has been properly disengaged with downward pressure on the shank of the hook. (12) Another benefit is the option of quickly removing a fishhook without anesthetic if you find yourself presented with an impaled person while minding your own business at a park or a lake. Dr. S. S. David of south Australia goes so far as to tout that this method has the benefit of not ruining the fisherman’s favorite lure by cutting off a barb. (12) Though cutting away the excess hooks (those not embedded) from a lure before yanking on it with a string, seems prudent to myself and others. (11)
Once the fishhook has been successfully removed, by either method, the question of infection control arises. Obviously, any wound should be thoroughly irrigated and cleaned. However, it is not an uncommon practice for fishermen to wash superficial injuries in the waters they are fishing. (14) Dr. Cooke even described this practice. (4) Most fishermen are unaware of the potentially serious pathogens, which inhabit nearly all bodies of fresh water.
The organisms responsible for the most complications are the Aeromonas species. While infections with these organisms are rare in otherwise healthy persons, they are common pathogens in otherwise healthy persons that have wounds which are exposed to fresh water, whether exposed directly or via a contaminated fishhook. (14,15,16) Aeromonas hydrophilia is a motile, facultative anaerobic gram negative rod, which is indigenous to fresh and brackish waters. It is usually resistant to ampicillin and first and second-generation cephalosporins (14,17,18).
It is usually treated with fluoroquinolones, most commonly ciprofloxacin. (14) Alternative drugs include trimethoprim-sulfamethoxazole, aztreonam, and third generation cephalosporins +/- aminoglycosides. (14) Commonly used oral cephalosporins, such as cephalexin, have no activity against Aeromonas and are insufficient for fresh water exposed wounds. (19,20)
Infections caused by Aeromonas hydrophilia can be invasive and are frequently rapidly progressive. In a report of 23 confirmed cases of Aeromonas wound infections following exposure to fresh water, 39% involved fascia, tendon, muscle, bone, or joints. (17)
Case reports have documented numerous severe infections due to Aeromonas after a seemingly trivial fishhook injury. The majority of these cases involve persons with comorbid conditions which compromise the immune or vascular systems. One case involved a 59-year-old diabetic man who sustained a very small fishhook puncture on his forearm. He removed the hook by himself and washed the wound in the lake where he was fishing. Within 36 hours he had developed septic shock.
Cultures eventually grew Aeromonas hydrophilia. Unfortunately, even after starting intravenous ciprofloxacin and ceftazidime, the infection progressed, resulting in formation of necrotizing myositis requiring surgical debridement, followed by eventual amputation of his limb above the elbow. While this is an extreme example, it does demonstrate the serious potential for fresh water exposed wounds in patients with immune or vascular compromise. These patients should always receive prophylactic antibiotics with Aeromonas coverage. (17,18) Even patients without comorbid conditions or relative compromise, should be closely examined and treated at the first sign or symptom of infection with suitable Aeromonas coverage. (14,19)
While there are no studies comparing different methods of fishhook removal, and no studies examining infection rates or pathogens following fishhook injury, and the only available literature consists of case reports and clinical anecdotes, I think that a reasonable approach to this problem can be synthesized. A little knowledge and some common sense should prevent a fishhook injury from becoming serious.
In conclusion, this will be my approach when next presented with a person impaled by a fishhook: (Assuming that the hook does not too closely approximate a vital structure or known neurovascular bundle.) I will clean and anesthetize the area. I will first employ the string method as described above, in hopes of avoiding extending the wound and field of contamination. If this method proves unsuccessful, I would resort to the push-through-and-cut technique.
http://www.kevinwakeman.com/fam/hookout.htm