10.17 Fishhook Removal
======================

agk's Library of Common Simple Emergencies

Presentation
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The patient has been snagged with a fishhook 
and arrives with it embedded in his skin.

What to do:
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- Cleanse the hook and puncture wound with 
    povidone-iodine or another antibiotic 
    solution. Provide tetanus prophylaxis as 
    needed. Most patients will benefit from 
    local infiltration of 1% buffered lidocaine 
    using a 27 gauge needle inserted through 
    the hole created by the fishhook.
- For hooks lodged superficially, first try the 
    simple "retrograde" technique. Push the 
    hook back along the entrance pathway while 
    applying gentle downward pressure on the 
    shank (like the downward pressure in the 
    "string" technique below). If the hook does 
    not come out, an 18 gauge needle may be 
    inserted into the puncture hole and used as 
    a miniature scalpel blade. Manipulate the 
    hook into a position so you can cut the 
    bands of connective tissue caught over the 
    barb and release it.
- For more deeply imbedded hooks, a more 
    complex technique of "needling" the hook 
    requires somewhat greater skill but also 
    allows you to work on an unstable skin 
    surface such as a finger or ear. Slide a 
    large gauge (#20 or #18) hypodermic needle 
    through the puncture wound alongside the 
    hook. Now blindly slide the needle opening 
    over the barb of the hook and, holding the 
    hook firmly, lock the two together. Now 
    with the barb covered, remove the hook and 
    needle as one unit.
- When a single hook is superficially embedded 
    in a stable skin surface such as the back, 
    scalp or arm, a simple way to remove it is 
    by using the "string" technique. Align the 
    shaft of the hook so that it is parallel to 
    skin surface. Press down on the hook with 
    your index finger to disengage the barb. 
    Place a loop of string (fishing line or 1-0 
    silk) over your wrist and around the hook, 
    and with a quick jerk opposite from the 
    direction the shaft of the hook is running, 
    pop the hook out. When done properly, this 
    procedure is painless and does not require 
    anesthesia. The hook may shoot out in the 
    direction that the string is being pulled, 
    so be careful that no one is standing in 
    the path of the fishhook.
- When the hook is deeply embedded, the barbed 
    end of the hook is protruding through the 
    skin, or you are unable to utilize the 
    previous techniques, proceed with the tried 
    and true "push through" maneuver. Locally 
    infiltrate the area with l% buffered 
    lidocaine and then push the point of the 
    hook along with its barb up through the 
    skin. Now with a pin cutter or metal snip, 
    cut off the tip of the hook and remove the 
    shaft or cut off the shaft of the hook and 
    pull the tip through.
- If a multifaceted (treble) hook is embedded, 
    cover the free hooks with corks or use a 
    pin cutter or metal snips to remove the 
    free hooks and protect the patient as well 
    as yourself from additional harm. When 
    significant manipulation is anticipated, 
    infiltrate first with 1% buffered 
    lidocaine.

What not to do:
---------------

- Do not try to remove a multiple hook or a 
    fishing lure with more than one hook 
    without first removing the free hooks or 
    embedding them in a protective material.
- Do not attempt to use the "string" technique 
    if the hook is near the patient's eye.
- Do not routinely prescribe prophylactic 
    antibiotics. Even hooks that have been 
    contaminated by fish rarely cause secondary 
    infection.

Discussion:
-----------

With the string, retrograde and needling 
techniques, there is no lengthening of the 
puncture track or creation of an additional 
puncture wound. The quickest and easiest method 
for removing a fishhook is the string 
technique. It is a technique you can use in the 
field because no special equipment or 
anesthesia is required, but it is not 
recommended when the hook is positioned on a 
skin surface that is likely to move when the 
string is pulled. This movement will cause the 
vector of force to change and therefore the 
barb may not release.

Illustration
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img/cse1017.gif

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