Contributor: Megan Hurley, MD

Educational Pearls:

Assess first: confirm the hook isn't near vital structures.

• Automatic subspecialty consult for eye involvement or proximity to carotid artery, radial artery, peritoneum, testicle, or urethra
• Barbed hook: cannot be pulled back through the entry without disengaging the barb

Removal Techniques

1. String-Pull: best for superficial, single-barbed hooks
   • Depress shank and eye of hook to disengage barb and then pull string taut and jerk suddenly along the long axis
   • Can only be used when the hook is in a body part that can be firmly secured so it won't move during the procedure
   • Little or no anesthesia needed
2. Push-Through & Snip: best choice when barb is near the skin surface
   • Anesthetize first and advance the hook forward until the barb emerges. Cut off the barb and then back hook out
   • Small exit wound, no sutures needed
3. Needle Cover: for larger hooks that are superficial
   • Anesthetize first and then slide an 18 or 20-gauge needle along the hook until the bevel covers the barb. Then back out the needle and hook together
4. Cut-it-out: last resort
   • Make an incision along the body of hook to barb and then remove hook

Adjuncts: Hydrodissection with lidocaine along the tract can ease removal
Post-Procedure

• Irrigate thoroughly and apply antibiotic ointment
• Routine prophylaxis not needed because complications are rare
  • Consider prophylactic antibiotics if hook is deeply embedded in high-risk area or contaminated by fresh water or salt water

References

1. Aiello LP, Iwamoto M, Guyer DR. Penetrating ocular fish-hook injuries. Surgical management and long-term visual outcome. Ophthalmology. 1992 Jun;99(6):862-6. doi: 10.1016/s0161-6420(92)31881-0. PMID: 1630774.
2. Malitz DI. Fish-hook injuries. Ophthalmology. 1993 Jan;100(1):3-4. doi: 10.1016/s0161-6420(93)31700-8. PMID: 8433823.

Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4

Contributor: Aaron Lessen MD

Educational Pearls:

• Recent prospective randomized clinical trial assessed optimal head-of-bed positioning in patients with LVO
  • 0º vs. 30º elevation
  • Objective was to determine superiority of the two angles in stability prior to thrombectomy for LVO patients
• 45 patients randomized to the group with 0° head positioning and 47 patients randomized to the group with 30° head positioning
  • Patients in the 30º group experienced worsening of NIHSS by 2 points or more
  • Patients with head position at 0° showed score stability
  • Hazard ratio 34.40; 95% CI, 4.65-254.37; P < .001
  • All-cause death occurred in 2 patients in the 0° group, compared with 10 patients in the 30° group.
• Results suggest that 0º positioning of the head of the bed may be protective to maintain clinical stability in patients with LVO prior to thrombectomy

References

1. Alexandrov AW, Shearin AJ, Mandava P, et al. Optimal Head-of-Bed Positioning Before Thrombectomy in Large Vessel Occlusion Stroke: A Randomized Clinical Trial. JAMA Neurol. 2025;82(9):905-914. doi:10.1001/jamaneurol.2025.2253

Summarized & Edited by Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Contributor: Meghan Hurley, MD

Educational Pearls:

1. Initial Assessment

• Start with a physical examination:

• • Determine if the bleed is anterior or posterior.

• Perform a primary survey: assess airway, breathing, and circulation (ABCs).

• • Airway compromise = intubation immediately.

• If the patient is stable, have them blow out any clots, then re-examine the nares.

2. Topical Medications

• Anesthetics: provide local anesthesia and pain relief.

• • Lidocaine

  • Tetracaine

• Vasoconstrictors: reduce bleeding.

• • LET (Lidocaine, Epinephrine, Tetracaine) is ideal because it provides anesthesia and vasoconstriction.

  • Cocaine pledgets (less common).

  • Tranexamic acid (TXA).

  • Oxymetazoline (Afrin).

• Cautery (Chemical): If an anterior bleed is visualized, silver nitrate can be applied for cauterization

3. Technique Tips

• Use a nasal speculum.

• • Spread up and down rather than side to side to avoid injury to the septum.

• Place LET-soaked gauze in the nares.

• Apply a nasal clamp for ~15 minutes to compress the vessels.

• Note that pledgets may cause upper lip numbness

4. Reassessment

• After 15 minutes, remove materials and inspect for a source of bleeding.

• If still bleeding and a source is identified, cauterize the site.

• Observe for 15 minutes to monitor for recurrence of bleeding.

5. Packing

• If the above measures fail to control bleeding:

• • Anterior packing:

  • • Nasal tampon (Merocel)

    • • Convenient for outpatient removal.

    • Balloon device

    • • Inflate the anterior balloon for compression.

  • Posterior packing:

  • • More complex, should consult ENT for additional assistance.

6. Disposition & Follow-Up

• Although rare, toxic shock syndrome is a possible complication of nasal packing.

  • Antibiotic prophylaxis is controversial, but may be considered in high-risk patients.

• Outpatient follow-up if stable:

  • Tampon: The patient can remove it at home.

  • Balloon: Return to ED for removal.

7. Risk Factors for Epistaxis & Prevention

• Deviated septum, dry environments, and anticoagulant use

  • Advise on humidifier use, nasal saline, and medication review to minimize future episodes.

References:

1. Tunkel DE, Anne S, Payne SC, et al. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngology–Head and Neck Surgery. 2020;162(1_suppl):S1-S38. doi:10.1177/0194599819890327

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons and Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/