Foreign Body Removal: Ticks, Rings, and Fish Hooks

imagesIndicated only if location of foreign body (FB) is certain


imagesRemoval may be done in 30 minutes or less


RELATIVE CONTRAINDICATIONS



imagesInvolvement of joint—orthopedic consultation may be required


imagesCoagulopathies or bleeding diathesis


imagesAllergy to anesthetic


imagesChronic medical problems that delay healing, such as diabetes, uremia, or immunocompromised state


imagesInvolvement of abdomen/pelvis/thorax


imagesNear major vascular structures that are difficult to visualize


imagesUncooperative, difficult, or intoxicated patient


imagesFB not localized


RISKS/CONSENT ISSUES



imagesProcedure can cause pain (local anesthesia will be given)


imagesLocal bleeding


imagesThere is potential for introducing infection (sterile technique will be utilized)


imagesRisk of injuring local neurovascular structures


imagesScar at site of FB removal


imagesPatient must be informed that all FBs may not be removed


imagesRetained wood FBs always develop an inflammatory response, but retained bullets rarely produce inflammation



imagesGeneral Basic Steps


   imagesLocalize the FB


   imagesPatient preparation


   imagesDecide on method of removal


TECHNIQUE



imagesLocalize the FB


   imagesGet multiple projections of plain x-ray using a soft-tissue technique (e.g., underpenetrated film); to locate radiopaque FBs, place a marker (i.e., needle) on the skin surface at the wound entrance before the x-ray procedure


   imagesAlthough glass and metal are easily located with plain films, ultrasonographic localization may be required for wood and thorns


   imagesAll intraorbital and intracranial FBs must be imaged by computed tomography (CT)


   imagesIf a patient has a previously explored wound demonstrating signs of infection, poor wound healing, or persistent pain, consider doing a CT


imagesPatient Preparation


   imagesSterilize and drape the area from where FB will be removed


   imagesAnesthetize area either via local infiltration or appropriate nerve block


imagesGeneral Removal Techniques


   imagesEnlarge the entrance to wound with an adequate skin incision


   imagesSpread the soft tissue with hemostats, avoiding use of fingers


      imagesHemostats can help find glass in a wound by creating a clicking sound when tapped against glass


   imagesIf visualization is inadequate, consider excision of small block of tissue, only if no significant neurovascular structures are involved


   imagesWhen searching for a thorn or needle, consider an elliptical incision, undermine the skin in all directions, and then compress the sides, expelling the FB


   imagesClosure of the wound after thorough irrigation is indicated unless exploring a contaminated wound


TICK REMOVAL



imagesNonmechanical means of tick removal is not recommended (i.e., drowning the tick in petroleum jelly), because it may cause the tick to regurgitate, increasing infection risk (FIGURE 84.1)


imagesMechanical removal


   imagesUsing the tip of forceps, grab the tick as close as possible to the patient’s skin, and apply steady traction


   imagesEnsure that all mouth parts are removed. Use an 18-gauge needle to remove retained pieces.


   imagesThoroughly cleanse the area with soap and water


imagesIn patients at high risk of Lyme disease, consider administration of 200 mg of doxycycline in a single dose (or amoxicillin in pediatrics) (Figure 84.1)



images


FIGURE 84.1 Tick removal. (From Bond GR. Envenomation management and tick removal. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Williams & Wilkins; 1997:1328, with permission.)

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Foreign Body Removal: Ticks, Rings, and Fish Hooks
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