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Emergency Department Use of an Eye Magnet for the Removal of Soft Tissue Foreign Bodies
CASE REPORT
Emergency Department Use of an Eye Magnet for the Removal of Soft Tissue Foreign Bodies
From the Department of Emergency Medicine, George Washington University, Washington, DC*; Alexandria Hospital, Alexandria, Virginia*; and William Beaumont Hospital, Troy, Michigan.* Receivedfor publication January 20, 1993. Accepted for publication March 30, 1993.
Joseph J Bocka, MD, FACEP* Jean Godfrey, MD"r
We used a Ralks eye magnet (no longer manufactured) to remove magnetic foreign bodies in four consecutive patients with metallic soft tissue foreign bodies. In all four cases, the foreign body was quickly located, requiring minimal soft tissue exploration, time, and radiography. [Bocka JJ, Godfrey J: Emergencydepartment use of an eye magnet for the removal of soft tissue foreign bodies. Ann Emerg Mefl February 1994;23:350-351.] INTRODUCTION Most soft tissue foreign bodies are notoriously difficult to remove, even when seen on plain film radiography or palpated. We report a method to aid in the removal of metallic magnetic foreign bodies using a portable nonelectric eye magnet.
CASE REPORTS Case 1 A 30-year-old woman presented to the emergency department complaining of left heel pain for one hour. She had stepped on a sewing needle and brought with her the piece that had broken off. Examination of the heel revealed a small puncture wound but no palpable foreign body. Radiographs revealed a 1-cm metallic foreign body approximately 1 cm beneath the skin. After routine sterile preparation, draping, and anesthetization of the heel, a sterile eye magnet was used to remove the needle fragment. Total time to retrieval, including preparation, was less than 15 minutes. Case 2 A 69-year-old woman presented to the ED stating that she had stepped on something and that it was still in her right foot. Radiographs revealed a 1.5-cm metallic foreign body in the soft tissue beneath her first and second metatarsals, lying about 1 cm deep. The foot was anesthetized after being sterilely cleansed and draped. Manual exploration for about ten minutes was unsuccessful in locating the foreign body, despite being able to visualize the puncture site. An ocular magnet then was used
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by one of the authors. A needle fragment was immediately localized and easily removed. Case 3 A 22-year-old man presented to the ED complaining of pain in his right eyelid. He had been chiseling a piece of metal, and a chip had broken off and struck him in the upper eyelid. Examination revealed a 2mm laceration to his left upper eyelid with what appeared to be a loose palpable foreign body. There was no evidence of globe, tear duct, nerve, or inner lid injury. No radiographs were obtained. After the usual preparation, drape, and anesthesia, manual exploration then was performed for ten minutes without being able to remove the foreign body. An ocular magnet then was used by one of the authors, with localization and removal of the metallic fragment within 15 seconds. Case 4 An obese 16-year-old boy presented to the ED complaining of right arm pain after being shot. Physical examination revealed a 7-mm entrance wound over the anterior portion of his mid-biceps region. There was pain with movement but no evidence of neurovascular injury. Radiographs showed a round 5-mm foreign body about 5 cm below the skin surface. An eye magnet was used, and a BB pellet was removed within about five minutes.
REFERENCES 1. Elder 13:System of Ophthalmology, Vo114,Part I: Mechanical Injuries. St Louis, Mosby, 1972, p616. 2. Ashkenazi E, Mualem N, Umansky F: Successful removal of an intracranial needle by an ophthalmologic magnet: Case report. J Trauma 1990;30:114-115.
DISCUSSION
Searching for and removing a soft tissue foreign body often are like looking for the proverbial needle in a haystack. Many patients who present to the ED for foreign body removal of a metallic foreign body often leave with the foreign body still present and sometimes with a hole that is bigger and more sore than when they presented. Since Hirschberg first introduced the principle in the 1870s, ophthalmologists have used strong electromagnets to remove ferromagnetic foreign bodies from the eye. 1 Electromagnets also have been used to remove foreign bodies from the brain 2 and sinuses. 3 Nonelectric magnets have been attached to catheter tips and used to remove foreign bodies from the bladder, 4 gastrointestinal tract, >8 and bronchial tree. 9 Magnetizing a forceps 1° or an otoscopic speculum 11 has been reported to be helpful in removing corneal and intra-auditory canal foreign bodies, respectively. To our knowledge, no one has reported the use of magnets to remove soft tissue foreign bodies in any setting. We used a handheld, sterilizable eye magnet that was tapered at one end. Once the area was prepared, a small nick usually was made through the entrance site to permit entrance of the magnet tip. The wound then was probed until a "click" was appreciated. The foreign body then could be removed while attached to the magnet. If much resistance was met, further, more directed wound exploFEBRUARY 1994
ration could be made with the foreign body localized via the magnet. Care should be used in patients with pacemakers or automatic implantable cardiac defibrillators as the eye magnet may activate or inactivate these inappropriately. Patients with either were excluded in our ED. Magnetic localization and removal provide a reasonable and cost-effective method of caring for patients with metallic soft tissue foreign bodies. Potentially, it could save money by leading to fewer consultations, referrals, and radiographs and less radiation exposure. Although the model we used is no longer manufactured, several handheld sterilizable eye magnets are available and range in cost from $75 to $500. Additionally, although many patients are not immediately endangered by having a foreign body present, most are quite satisfied when it can be removed in the ED rather than leaving it or having it removed at a later date.
23:2
ANNALS OF EMERGENCY MEDICINE
3. Calhoun KH, Peters BR, Stiernberg CM, et al: Magnet extraction of frontal sinus foreign body. Otolaryngol Head Neck Surg 1988;99:75-77. 4. Wise KL, King LR: Magnetic extraction of intravesical foreign body. Urology1989;33:62-63. 5. Towbin RB, DunbarJS, Rice S: Magnetic catheter for removal of magnetic foreign bodies. AJR 1990;154:149-150. 6. Himadi GM, FischerGJ: Magnetic removal of foreign bodies from the upper gastrointestinal tract. Radiology 1977;7:226-227. 7. Paulsen EK, Jaffee RB: Metallic foreign bodies in the stomach: Fluoroscopicremoval with a magnetic orogastric tube. Radiology 1990:174:191-194. 8. Voile E, Hanel D, Beyer P, et al: Ingested foreign bodies: Removal by magnet. Radiology 1986;160:407-409. 9. Saite H, Saka H, Sakai S, et al: Removal of broken fragment of biopsy forceps with magnetic extractor. Chest 1989;95:700-701. 10. Arnold RW, Erie JC: Magnetized forceps for metallic corneal foreign bodies (letter).
Arch Ophthalmol 1988;106:1502. 11. Mattucci KF, GlassWM, Setzen M: Removalof metallic foreign bodies of the external auditory canal, lot Surg 1987;72:65.
Reprint no. 47/1/52669 Address for reprints: JosephJ Bocka,MD, FACEP GeorgeWashingtonUniversitySchoolof Medicine 2140 PennsylvaniaAvenueNW, BuildingW Washington, DC20037 202-994-3921 Fax202-994-3924
351
Emergency Department Use of an Eye Magnet for the Removal of Soft Tissue Foreign Bodies
From the Department of Emergency Medicine, George Washington University, Washington, DC*; Alexandria Hospital, Alexandria, Virginia*; and William Beaumont Hospital, Troy, Michigan.* Receivedfor publication January 20, 1993. Accepted for publication March 30, 1993.
Joseph J Bocka, MD, FACEP* Jean Godfrey, MD"r
We used a Ralks eye magnet (no longer manufactured) to remove magnetic foreign bodies in four consecutive patients with metallic soft tissue foreign bodies. In all four cases, the foreign body was quickly located, requiring minimal soft tissue exploration, time, and radiography. [Bocka JJ, Godfrey J: Emergencydepartment use of an eye magnet for the removal of soft tissue foreign bodies. Ann Emerg Mefl February 1994;23:350-351.] INTRODUCTION Most soft tissue foreign bodies are notoriously difficult to remove, even when seen on plain film radiography or palpated. We report a method to aid in the removal of metallic magnetic foreign bodies using a portable nonelectric eye magnet.
CASE REPORTS Case 1 A 30-year-old woman presented to the emergency department complaining of left heel pain for one hour. She had stepped on a sewing needle and brought with her the piece that had broken off. Examination of the heel revealed a small puncture wound but no palpable foreign body. Radiographs revealed a 1-cm metallic foreign body approximately 1 cm beneath the skin. After routine sterile preparation, draping, and anesthetization of the heel, a sterile eye magnet was used to remove the needle fragment. Total time to retrieval, including preparation, was less than 15 minutes. Case 2 A 69-year-old woman presented to the ED stating that she had stepped on something and that it was still in her right foot. Radiographs revealed a 1.5-cm metallic foreign body in the soft tissue beneath her first and second metatarsals, lying about 1 cm deep. The foot was anesthetized after being sterilely cleansed and draped. Manual exploration for about ten minutes was unsuccessful in locating the foreign body, despite being able to visualize the puncture site. An ocular magnet then was used
350
ANNALS OF EMERGENCY MEDICINE 23:2
FEBRUARY1994
EYE M A G N E T
Bocka & Godfrey
by one of the authors. A needle fragment was immediately localized and easily removed. Case 3 A 22-year-old man presented to the ED complaining of pain in his right eyelid. He had been chiseling a piece of metal, and a chip had broken off and struck him in the upper eyelid. Examination revealed a 2mm laceration to his left upper eyelid with what appeared to be a loose palpable foreign body. There was no evidence of globe, tear duct, nerve, or inner lid injury. No radiographs were obtained. After the usual preparation, drape, and anesthesia, manual exploration then was performed for ten minutes without being able to remove the foreign body. An ocular magnet then was used by one of the authors, with localization and removal of the metallic fragment within 15 seconds. Case 4 An obese 16-year-old boy presented to the ED complaining of right arm pain after being shot. Physical examination revealed a 7-mm entrance wound over the anterior portion of his mid-biceps region. There was pain with movement but no evidence of neurovascular injury. Radiographs showed a round 5-mm foreign body about 5 cm below the skin surface. An eye magnet was used, and a BB pellet was removed within about five minutes.
REFERENCES 1. Elder 13:System of Ophthalmology, Vo114,Part I: Mechanical Injuries. St Louis, Mosby, 1972, p616. 2. Ashkenazi E, Mualem N, Umansky F: Successful removal of an intracranial needle by an ophthalmologic magnet: Case report. J Trauma 1990;30:114-115.
DISCUSSION
Searching for and removing a soft tissue foreign body often are like looking for the proverbial needle in a haystack. Many patients who present to the ED for foreign body removal of a metallic foreign body often leave with the foreign body still present and sometimes with a hole that is bigger and more sore than when they presented. Since Hirschberg first introduced the principle in the 1870s, ophthalmologists have used strong electromagnets to remove ferromagnetic foreign bodies from the eye. 1 Electromagnets also have been used to remove foreign bodies from the brain 2 and sinuses. 3 Nonelectric magnets have been attached to catheter tips and used to remove foreign bodies from the bladder, 4 gastrointestinal tract, >8 and bronchial tree. 9 Magnetizing a forceps 1° or an otoscopic speculum 11 has been reported to be helpful in removing corneal and intra-auditory canal foreign bodies, respectively. To our knowledge, no one has reported the use of magnets to remove soft tissue foreign bodies in any setting. We used a handheld, sterilizable eye magnet that was tapered at one end. Once the area was prepared, a small nick usually was made through the entrance site to permit entrance of the magnet tip. The wound then was probed until a "click" was appreciated. The foreign body then could be removed while attached to the magnet. If much resistance was met, further, more directed wound exploFEBRUARY 1994
ration could be made with the foreign body localized via the magnet. Care should be used in patients with pacemakers or automatic implantable cardiac defibrillators as the eye magnet may activate or inactivate these inappropriately. Patients with either were excluded in our ED. Magnetic localization and removal provide a reasonable and cost-effective method of caring for patients with metallic soft tissue foreign bodies. Potentially, it could save money by leading to fewer consultations, referrals, and radiographs and less radiation exposure. Although the model we used is no longer manufactured, several handheld sterilizable eye magnets are available and range in cost from $75 to $500. Additionally, although many patients are not immediately endangered by having a foreign body present, most are quite satisfied when it can be removed in the ED rather than leaving it or having it removed at a later date.
23:2
ANNALS OF EMERGENCY MEDICINE
3. Calhoun KH, Peters BR, Stiernberg CM, et al: Magnet extraction of frontal sinus foreign body. Otolaryngol Head Neck Surg 1988;99:75-77. 4. Wise KL, King LR: Magnetic extraction of intravesical foreign body. Urology1989;33:62-63. 5. Towbin RB, DunbarJS, Rice S: Magnetic catheter for removal of magnetic foreign bodies. AJR 1990;154:149-150. 6. Himadi GM, FischerGJ: Magnetic removal of foreign bodies from the upper gastrointestinal tract. Radiology 1977;7:226-227. 7. Paulsen EK, Jaffee RB: Metallic foreign bodies in the stomach: Fluoroscopicremoval with a magnetic orogastric tube. Radiology 1990:174:191-194. 8. Voile E, Hanel D, Beyer P, et al: Ingested foreign bodies: Removal by magnet. Radiology 1986;160:407-409. 9. Saite H, Saka H, Sakai S, et al: Removal of broken fragment of biopsy forceps with magnetic extractor. Chest 1989;95:700-701. 10. Arnold RW, Erie JC: Magnetized forceps for metallic corneal foreign bodies (letter).
Arch Ophthalmol 1988;106:1502. 11. Mattucci KF, GlassWM, Setzen M: Removalof metallic foreign bodies of the external auditory canal, lot Surg 1987;72:65.
Reprint no. 47/1/52669 Address for reprints: JosephJ Bocka,MD, FACEP GeorgeWashingtonUniversitySchoolof Medicine 2140 PennsylvaniaAvenueNW, BuildingW Washington, DC20037 202-994-3921 Fax202-994-3924
351