METALLIC NEEDLES Long, thin foreign bodies such as sewing and hypodermic needles may be difficult to locate in soft tissue. Two techniques are available for removing needles that are parallel to the surface of the skin. If the needle is superficial enough to be palpable, an incision is made at one end to expose and grasp it with a hemostat. If the needle is deep, an incision is made perpendicular to the needle at its midpoint, where it can be clamped with a hemostat and pushed out of the entrance of the original wound (Fig.42-2).
FIG. 42-2. A. (Plate...4) An incision is made perpendicular to the needle at its midpoint. B. The needle is grasped through the incision with a hemostat and backed out of the puncture wound.
Long, thin foreign bodies that are oriented perpendicular to the skin surface can be elusive. If a needle can be reached with an alligator forceps or hemostat, it can be pulled straight out. If a needle lies beyond the reach of a hemostat, the entrance wound must be enlarged with a skin incision ( Fig, 4.2-3.). However, the incision can easily pass to the side of the object, so the skin edges should be undermined, and pressure applied on the skin edges may displace the foreign body into the center of the wound, where it can be seen and grasped. Once removed, the needle and the wound should be inspected to ensure that the object was removed in its entirety.
FIG. 42-3. A. The entrance site is enlarged with a skin incision. B. If the incision passes to the side of the object, the skin is undermined. C. (Plate.. ..5.) Pressure on the skin edges displaces the foreign body into the center of the wound.
WOOD SPLINTERS AND ORGANIC SPINES Solid foreign bodies can be pulled out of puncture wounds with forceps, but wood splinters and organic spines (e.g., cactus, sea urchin, and fish) may disintegrate with this technique. Only superficial splinters that are a few millimeters long can be grasped and removed with a fine-point splinter forceps. A splinter parallel to the skin surface should be lifted out of the wound after incising the skin along the long axis of the object ( Fig 42-4). If the splinter is lodged in the subcutaneous tissue, the entrance wound must be enlarged with a skin incision so that the foreign body can be grasped under direct visualization. Wood fragments may be impossible to locate precisely. One solution is to create an elliptical incision around the puncture wound and extract the fragment in a block of tissue (Fig 42-5.). The physician should avoid incorporating nerves, vessels, or tendons within the excised block. Either technique creates a larger wound but allows a better inspection and more thorough cleaning after removal.
FIG. 42-4. To remove a friable foreign body such as a wood splinter that is parallel to the skin surface, an incision is made along its long axis. The object can be lifted out and the entire length of the wound inspected for remnants.
FIG. 42-5. Block excision is effective for foreign bodies that are friable, difficult to find, buried in fatty tissue, or stain surrounding tissue. A. A small, elliptical incision is made around the original wound. B. (PJate.,6) Ihe incision is undercut until contact is made with the foreign body. C. Ihe block of tissue is grasped with a forceps, the foreign body is clamped with a hemostat, and both are removed.
Subungual splinters must be removed because subsequent infection is almost inevitable, and the distal phalanx is at risk for osteomyelitis. If the splinter is underneath the distal end of the nail, it can be grasped by a splinter forceps or hooked by a hypodermic needle bent at its tip. More proximal splinters can be reached by anesthetizing the finger and removing a wedge of the nail overlying part of the foreign body ( Fig 42.-6). If pieces of the splinter remain, the entire nail can be removed.
FIG. 42-6. Subungual foreign bodies that are beyond the reach of a splinter forceps can be exposed by excising a wedge of the overlying nail.
Numerous, tiny cactus spines in the dermis can be plucked out individually with forceps or extracted together with depilatory wax, professional-quality facial gel, rubber cement, or household glue.2021 Larger spines and thorns should be removed with incision or excision techniques.
FISHHOOKS Fishhooks have a variety of sizes and shapes based on a common pattern (Fig 42-7). Ihe barb, which is a projection extending backward from the point of the hook, keeps the point embedded in the fish's mouth and makes removal from skin a challenging task. Most injuries with fishhooks involve the hand, head, or face.
Several methods for removing fishhooks in skin have been reported. Ihe best strategy depends primarily on the depth of the hook. If the hook has multiple barbs, precautions should be taken to avoid impaling the treating physician, bystanders, or the patient (a second time) during removal by taping or cutting off the exposed barbs. With any technique, the skin should be prepared and anesthetized at the entry site. If the hook is superficial, gentle downward pressure is placed on the shank while the hook is simply pulled in a retrograde direction along the path of entry ( Fig.,42-8).
FIG. 42-8. Simple retrograde technique. While pressing the skin over the tip of the hook to disengage the barb and applying gentle downward pressure on the shank, the physician backs the hook out of the skin. If the barb catches on skin fibers, other techniques must be used.
Ihe string-pull method is a variation on the retrograde technique. String is wrapped around the bend of the hook where it enters the skin. Ihe end of the shank is depressed with one hand to disengage the barb from deeper tissue. Ihe other hand then gives a quick pull on the string, extracting the hook ( Fig.,42-9). Ihe disadvantages of this technique are that failure can cause further pain to the patient and success can result in ripped tissue or a sharp, blood-contaminated object flying uncontrollably across the room.
FIG. 42-9. String-pull technique. String or suture material is tied to the curve of the hook. The hook is positioned as described in the simple retrograde technique, and a quick pull on the string will dislodge the hook.
The needle-cover technique requires physician dexterity. An 18-gauge needle is inserted into the entrance wound alongside the shank of the hook. The needle follows the bend of the hook until the lumen of the needle can be placed over the barb to sheathe it. The hook and needle are then withdrawn from the wound as a unit ( Fig. 42-10).
FIG. 42-10. Needle-cover technique. The area is anesthetized, and an 18-gauge needle is inserted into the entrance wound along the hook. The lumen of the needle is placed over the barb to cover it, and both the hook and needle are backed out of the wound.
The advance-and-cut technique is another alternative (Fig 42.-11). The tip of the hook is advanced through the skin surface. Once exposed, the point and barb are cut with wire cutters, and the remaining part of the hook is rotated out of the original wound. If barbs along the shank are embedded beneath the dermis, the shank can be clipped near the hook's eye. The remaining part of the hook is then passed antegrade through the skin. Since the advance-and-cut method further traumatizes and contaminates tissue, it probably should be reserved for wilderness situations. However, this may be an effective method in the ED if the barb has nearly or already penetrated the surface of the skin or is embedded within a joint, cartilage, or tendon.
FIG. 42-11. Advance-and-cut technique. The area is anesthetized, and the tip of the hook is advanced through the skin surface (A), the barb is cut (B), and the hook is rotated back out of the original wound (C).
A fifth technique requires the services of a physician but has important advantages over other methods. When the barb penetrates into the dermis, it usually cannot be backed out or pulled out of the wound. In these cases, the entrance wound should be enlarged 2 to 3 mm with a No. 11 scalpel blade. A small incision is carried along the bend of the hook to the barb until the barb is disengaged from the soft tissue. The hook can then be withdrawn easily through the larger entrance ( Fig. 4.2-12). If necessary, the barb can be grasped with a hemostat to prevent it from snagging tissue on the way out. There are two major benefits to enlarging puncture wounds containing foreign bodies. First, the wound is more easily inspected for additional foreign bodies. In the case of fishhook impalement, the wound may be harboring the bait that was on the hook. Second, the wound tract is more easily irrigated through a larger opening. However, the physician must avoid injuring tendons, nerves, or vessels with the scalpel.
FIG. 42-12. Incision technique. The area is anesthetized, and a small incision is made along the shaft of the hook to the barb. The hook is withdrawn through the incision.
TRAUMATIC DERMAL TATTOOING Foreign particulates may be embedded in the epidermal and dermal layers of skin by an abrasion, which permanently stains or
"tattoos" the surrounding tissue. If vigorous scrubbing does not remove the particulates, the patient can be referred to specialists for dermabrasion or block excision. The graphite from pencil lead can produce a pigmentation that will never dissolve, and graphite tattoos should be excised in cosmetic areas.
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This ebook provides an introductory explanation of the workings of the human body, with an effort to draw connections between the body systems and explain their interdependencies. A framework for the book is homeostasis and how the body maintains balance within each system. This is intended as a first introduction to physiology for a college-level course.