Sanguine Hook

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Sanguine Hook is an active item added in The Reheated Update.


  • On use, Isaac holds up a large fishing hook attached to him by a reel, which can be thrown in the cardinal directions.
    • When the hook collides with an enemy, the hook will deal 50% of Isaac's damage on hit and dig into them, which bruises them and drags them towards Isaac until the item is used again.
      • Once the hook is manually released from the enemy, it deals 100% of Isaac's damage to the enemy and creates a random volley of bloody tears in the direction the hook was released from, and the enemy will begin hemorrhaging — causing them to bleed red creep and bloody projectiles which damage other enemies — for 6 seconds.
    • When the hook collides with a pickup or item pedestal, it will be dragged towards Isaac until the item is used again or the hook is close enough to him. Pickups and items are able to be dragged across rocks and pits.
    • When the hook collides with a wall, reaches its maximum range, or the item is used again, it will be reeled back towards Isaac.


  • The hook can be thrown over rocks and obstacles.
  • The damage of the volley of bloody tears created after the initial hook pull-out will harm other enemies, and each tear deals a random amount of damage between 3.15-4.20.
  • Bruise can increase the damage over time caused by hemorrhaging, meaning an enemy that is currently bleeding from having the hook pulled out can be hooked again to take more damage over time.
  • Enemies that teleport, jump or burrow away while hooked can cause the hook to be released from them, without causing them to begin hemorrhaging.
  • The thrown hook can grab and drag around Randy The Snail Randy The Snail and Pet Rock Pet Rock.
  • Hooking onto a Nickel.png Sticky Nickel for long enough will cause it to un-stick, turning it back into a regular Nickel.


  • Second Hand.png Second Hand: Increases the duration of the hemorrhaging by 6 seconds, and increases it by an additional 6 for every Mom's Box.png Trinket Multiplier.
    • No effect on the bruise duration, as it only stays applied for as long as an enemy is hooked and is not based on a timer.
  • JudasCoopIcon.png Judas + Birthright.png Birthright: Judas gains +2 damage while an enemy is hooked. If the hook is removed, the damage up disappears.


  • The item is a reference to Sanford from the Madness Combat series, a character who often fights with a very large hook.
    • Isaac's appearance when he collects the Sanguine Hook is also based directly on Sanford's own iconic bandana he wears.
    • The flavor text likely refers to the flavor text for unobtainable items in Madness: Project Nexus Classic, which similarly call out the player for cheating items into their inventory.
  • The appearance of the thrown hook becomes bloody after being released from an enemy. This is only cosmetic.


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