IV needle broke off in arm or neck... intraluminal removal?

[Angry Birds]

Do you guys ever remove these yourselves? I can't imagine doing it in the neck, but what about from the arm?

I've only seen this a couple times and shipped both to a place with vascular surgery, but then I saw that one of my colleagues just removed it himself. I had thought that this was a very high risk procedure and should be done endovascularly or something or the other... Am I wrong and just being a wuss?

How do you do it if you have to remove it, especially if it is intraluminal, i.e. in the vein?

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[Millennial ER Doc]

I'm surprised I've never seen this before (and I trained in a place w/ a lot of IVDA)

Is the needle sticking out of the skin? If so, I'd probably remove it... assuming it wasn't in a precarious area of the body (i.e. the neck) and I could just clamp/pull it out.

If it requires me digging around SubQ, I wouldn't. I guess the big risk is if you accidentally push the shard further into the vessel, potentially making it a very sharp foreign body embolus... that would be a bad time

* like I said though, never seen one of these managed before.

** I do remember a co-resident leaving a guide-wire in during their MICU rotation... hugely embarrassing . Vascular spent a long time fishing it out from what I recall.

 

[Angry Birds]

I'm surprised I've never seen this before (and I trained in a place w/ a lot of IVDA)

Is the needle sticking out of the skin? If so, I'd probably remove it... assuming it wasn't in a precarious area of the body (i.e. the neck) and I could just clamp/pull it out.

If it requires me digging around SubQ, I wouldn't. I guess the big risk is if you accidentally push the shard further into the vessel, potentially making it a very sharp foreign body embolus... that would be a bad time

* like I said though, never seen one of these managed before.

** I do remember a co-resident leaving a guide-wire in during their MICU rotation... hugely embarrassing . Vascular spent a long time fishing it out from what I recall.

Yes these are needles that you cannot see and are just under the skin. I agree with the risks but just want to make sure others agree and I’m not shipping something I shouldn’t.

 

[scummie]

New grad, this is not something we ever did in residency. Do not have vascular where I work now, would definitely ship. Like Millennial said, unless it's exposed and in an easy-to-get-to spot, not the neck, may try to pull out. I'm not gonna go around digging in there though with an 11 blade and some forceps.

 

[deleted109597]

Comfort level. If you're the only person at your shop not doing it, the director will get complaints. If you're the only one doing it, you'll get complaints.

 

[The White Coat Investor]

Yes these are needles that you cannot see and are just under the skin. I agree with the risks but just want to make sure others agree and I’m not shipping something I shouldn’t.

I do lots of FB removals like that using fluoroscopy. But I'm not doing it INSIDE blood vessels. I'm digging it out of soft tissue just under the skin. If I had any concern it was inside a vessel, no way would I go after it. That sounds way out of my scope of practice.

I don't recall ever going after a needle an IVDAer broke off. It's usually someone who stepped on something or the latest put her finger under a sewing needle. Went in at the base of the fingernail, I pulled it out from a small incision I made in the finger pad.

I don't know that I would avoid doing one JUST BECAUSE it was in the neck, but I'd certainly have a much lower threshhold to involve someone else like surgery. Typically this is hand/foot/limb for me.

 

[Rendar5]

IVDA w/ a lost needle? d/c home w/ outpt f/u w/ surgery. Not really an emergency. These are not in the blood vessel, they're in the subQ tissue. It's the same as any subQ FB I can't remove myself. I did it once and I ended up needing fluoro to do it, but typically don't have easy acess to fluro. Since then I don't bother to attempt unless it's a big needle that I can see visually.

 

[Epinephreus]

My residency sees tons of IVDU and I have done a few of these, never in a blood vessel, always in Sub-q.

What has worked for me is using US. Linear probe, I will take a very small needle (29-30g 1.5 in) and direct it to the FB under US. Then I take a scalpel and make a very small incision down along the needle to the FB and remove it with forceps. And as an extra pro tip, when giving the lidocaine, also guide it down to the FB and and inject to "dissect" around the FB - makes it easier to grab.

 

[Angry Birds]

IVDA w/ a lost needle? d/c home w/ outpt f/u w/ surgery. Not really an emergency. These are not in the blood vessel, they're in the subQ tissue. It's the same as any subQ FB I can't remove myself. I did it once and I ended up needing fluoro to do it, but typically don't have easy acess to fluro. Since then I don't bother to attempt unless it's a big needle that I can see visually.

Ok stupid question: how do I know if it’s in the vein or subq?

 

[Rendar5]

Ok stupid question: how do I know if it’s in the vein or subq?

Bedside ultrasound can be pretty effective if you’re ever unsure. It’s always migrated to the subQtissue in my cases. but if you truly saw it lying in a vein then I could understand sending it to a place with vascular

 

[BoardingDoc]

Bedside ultrasound can be pretty effective if you’re ever unsure. It’s always migrated to the subQtissue in my cases. but if you truly saw it lying in a vein then I could understand sending it to a place with vascular

Agreed. If you can't tell by examining them, just throw a probe on their arm/neck/whatever. Instant answer. Even if it isn't in a vessel but is deep/near a vessel/you otherwise don't want to remove it, you can always consult gen surg at your shop or have them followup as an outpatient instead of transferring.

 

[NITRAS]

I had an IV catheter tip get broken off and was lodged in this guys arm (who was a well known drug seeking toad). Called vascular, who punted to general surg, who wanted ortho.......it was so much fun.

 

[Groove]

Ok stupid question: how do I know if it’s in the vein or subq?

US

That being said, these are notoriously difficult to find even with fluoro. At my shop, GS and Ortho routinely punt these back and forth to each other and I'm chuckling as I read this thread thinking of a similar case one of our GS took to the OR just last week for an extremely superficial needle (in context of phlegmon) and couldn't find it after an hour of fluoro and surgical exploration.

If they have an abscess or other high risk features, I'll admit these and punt to the appropriate surgical specialist. I don't think I've ever had a completely 100% intraluminal needle where I needed to consult vascular. Simple ones with no complication...I think it's reasonable to have f/u with a surgeon after consult. I don't dig for these anymore whatsoever as I learned my lesson a long time ago. Once you commit, it's a complete roll of the dice and on a busy shift I don't like those odds.

 

[deleted109597]

That being said, these are notoriously difficult to find even with fluoro. At my shop, GS and Ortho routinely punt these back and forth to each other and I'm chuckling as I read this thread thinking of a similar case one of our GS took to the OR just last week for an extremely superficial needle (in context of phlegmon) and couldn't find it after an hour of fluoro and surgical exploration.

They're trying to be too gentle. Find the needle on US,XR,Fluoro. Orient 11 blade perpendicular. Cut down. You'll hit it. Once you hit it, grab it with hemostats. Dissect out.

 

[Groove]

They're trying to be too gentle. Find the needle on US,XR,Fluoro. Orient 11 blade perpendicular. Cut down. You'll hit it. Once you hit it, grab it with hemostats. Dissect out.

I'll be happy to dissect with a vertical 11 blade in a glut, but the antecubital fossa? No thanks. The antecubital fossa anatomy is complex and even with surgeons is one of the areas well known for increased surgical complications. The needle is usually always going to be near or within a vascular structure, why risk transecting anything outside a controlled and bloodless surgical environment? If you are diving with an 11 blade, even with US, your margin of error is small. I've honestly never worked with anyone that went for these in the ED. It's enlightening to know that some of you do!

 

[Angry Birds]

So glad I made this thread and got all your expert opinions. Thank you!!

 

[dchristismi]

Eh, just stick 'em in the MRI, hold some direct pressure and your problem is solved.

I jest.
I hope that was obvious.
A little slap happy after 3 overnights, a 2h not-really-sleeping/dozing nap and, oh, wine.

 

[deleted109597]

Most of mine aren't in the AC fossa anymore. They've already ruined those veins. I might not dig in there as hard.

 

[thegenius]

I can see the problem with dissecting down is the patient will just bleed making it harder to see. If you don't have cautery it can just be frustrating. You might have a second or two to see what's going on before the field builds up with blood.

 

[deleted109597]

Not going by vision. It's a metal object you're hunting with metal objects. You'll feel it.

 

[RoyBasch]

I have a very low threshold to bail on foreign bodies of all kind. In my mind they are generally not an emergency and I am happy to turf them to whatever respective surgeon to wrestle with outpatient. Generally speaking they are frequently much harder than they appear.

To answer the OP's original question, I probably would not even try if it were in the antecubital fossa. That is an anatomically complex and hazardous region. Would probably arrange for close follow up with orthopedic surgeon.

 

[seebelcherrun]

we routinely sent these home if not associated with abscess or hematoma. usually not intraluminal but subq. can have removed as an outpatient.

But i always thought it'd make sense to use a magnet. I guess depending on what type of metal their needle was made out of.

 

[MechEDoc]

I use MRI to find the needle.100% of the time it's extracted and stuck to the machine before the study is complete...

 

[MechEDoc]

we routinely sent these home if not associated with abscess or hematoma. usually not intraluminal but subq. can have removed as an outpatient.

Where are you guys working? I have worked in IVDU country, but haven't had a broken needle foreign body yet!