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Case report
peer-reviewed

Self-inflicted Cardiac Injury with Nail Gun Without Hemodynamic Compromise: A Case Report



Abstract

Pneumatically powered nail guns have been used in construction since 1959. Penetrating injuries to the heart with nail guns have a wide range of presentations from asymptomatic to cardiac tamponade and exsanguination. Mortality related to cardiac nail gun injuries is similar to knife injuries, estimated at 25%. Surgical exploration is the treatment of choice. We describe a case of self-inflicted nail gun injury to the chest without hemodynamic compromise in a 51-year-old man. Computed tomography (CT) imaging confirmed nail penetrating the right ventricle, with the tip adjacent to but not violating the abdominal aorta. The patient was successfully treated with thoracotomy and foreign body removal.

Introduction

Pneumatically powered nail guns have been used in construction since 1959. Low-velocity nail guns are primarily used on wooden surfaces while their high-velocity counterparts drive nails into concrete or metal. In the medical literature, nail guns have mostly been described causing orthopedic injuries of the non-dominant arm. However, life threatening cardiac injuries have also been reported, especially self-inflicted cases [1]. Penetrating injuries to the heart with nail guns have a wide range of presentations from asymptomatic to cardiac tamponade and exsanguination. Mortality related to cardiac nail gun injuries is more similar to knife injuries than gunshot injuries, estimated at 25% [1]. Surgical exploration is the treatment of choice [2-10]. However, conservative management has been reported successful in asymptomatic cases [1]. We describe a case of self-inflicted nail gun injury to the chest without hemodynamic compromise in a 51-year-old man. Informed consent was obtained from the patient for this study.

Case Presentation

A 51-year-old white man with past medical history of depression and multidrug abuse presented to our emergency department with altered mental status and complaining of chest pain. Limited history suggested the patient was binge drinking and discharged a nail gun into his chest in a suicide attempt. However, the resulting chest pain became unbearable causing him to call a friend for transport to the emergency department. Past medical history included major depressive disorder, alcohol, tobacco and cocaine abuse, and chronic obstructive pulmonary disease (COPD). Investigations into his social history suggested his wife had died six months ago and he had been abusing alcohol, tobacco, cocaine, and marijuana heavily since. Vital signs did not suggest hemodynamic compromise: pulse was 93 bpm, blood pressure was 100/60 mmHg, and respirations were at 14 breaths/minute. The examination revealed that he was an overweight white man, weighing 75 kg and measuring 178 cm in stature. The patient was alert, although confused. A head exam showed temporal wasting and poor dental health. The pulses in the extremities were diminished but palpable, and carotid upstrokes were felt bilaterally. One puncture wound at the right sternal border between the fourth and fifth ribs was present. Additionally, the patient had decreased capillary refill and increased AP diameter. The rest of the physical exam including the cardiac and pulmonary exam were normal.

Laboratory investigations showed an elevated WBC count at 13,000/mcL and ethanol serum level at 156 mg/dL. Otherwise, his complete blood count, metabolic panel, and liver function tests were normal. Chest X-ray (Figures 1-2) and computed tomography (CT) of the chest (Figures 3-5) revealed a three-inch tapered foreign body consistent with a nail, with the tip adjacent to the abdominal aorta. The tail end of the nail was located within the right ventricular wall. Remarkably, he was not hemodynamically compromised and consented to immediate surgery for removal of the nail.

 
 

 

 
 
 

An intraoperative transesophageal echocardiogram confirmed the location of the nail and normal physiologic cardiac function. A median sternotomy was performed. The patient was found to have extensive pericarditis, and dissection down to the heart was required. The nail had punctured entirely through the anterior right ventricular wall, left atrium, the diaphragm, and into the abdomen, with the tail end remaining in the posterior right ventricular wall. Removal of the nail and closure of the two heart wounds and diaphragm with Prolene® Suture (Ethicon, NJ, USA) was uncomplicated. The chest was closed following the placement of two pacing wires and thoracostomy tube. Postoperative echocardiogram showed no physiologic changes from prior to removal of the foreign body. The patient did well and was extubated immediately following surgery. The patient was held for psychiatric evaluation, but was eventually discharged on postoperative day 8.

Discussion

In the majority of cases, penetrating cardiac trauma occurs secondary to gunshot or stab wounds with reported mortality rates of 60–93% and 22–62%, respectively. Nail gun wounds are much rarer, and one case series has suggested the mortality to be close to 25%. This may be due to the smaller impact behind the projectiles relative to guns and the small frontal cross-sectional area, which focuses impact on a point. Indeed, we find several other reports similar to ours in which a patient suffering chest penetration from a nail gun, regardless of intention, had asymptomatic or delayed presentation [3, 5-6, 8, 10]. This is not to say that nail gun injuries are benign, as penetrating chest injury by nail gun has also led to catastrophic hemodynamic insufficiency [2, 4, 7, 9]. The wide range of presentations is likely due to the nail guns’ wide range of muzzle energies, lack of stabilization, and poor accuracy.

Surgery is the accepted treatment regardless of hemodynamic stability. Unstable patients should be taken immediately to the operating room. More stable patients can receive imaging such as routine chest radiograph or CT scan to help diagnose complications such as hemothorax, hemopericardium, pneumopericardium, and others [7]. CT should only be attempted on stable patients, but is particularly useful in reconstructing the track of the penetrating object and possible migration. Intraoperative transesophageal echocardiogram has been reported to be helpful in guiding surgical treatment [7, 10]. In this case, the patient was stable enough to undergo preoperative imaging, which helped guide operative therapy.

Conclusions

Nail gun injuries to the heart, while rare, are potentially fatal and need immediate evaluation and treatment. In most cases, diagnosis can be made with history and detailed physical exam. Hemodynamically unstable patients should be operated on immediately, while imaging on stable patients can assist in the diagnosis of the penetrating agent and further complications. A CT investigation is particularly helpful in the determination of the projectile track. All patients should be considered for surgery regardless of stability. In our case, the patient was fortunate to have missed his own abdominal aorta, other great vessels, or cardiac valves, which may have led to his demise.


References

  1. Vosswinkel JA, Bilfinger TV: Cardiac nail gun injuries: lessons learned. J Trauma. 1999, 47:588-590. 10.1097/00005373-199909000-00032
  2. Beaver AC, Cheatham ML: Life-threatening nail gun injuries. Am Surg. 1999, 65:1113-6.
  3. Carr CS, Alkhafaji S, Alkhulaifi AM: Penetrating cardiac nail gun injury. Emerg Med J. 2008, 25:313. 10.1136/emj.2006.040121
  4. Felner JM: Images in clinical medicine. Nail in the aorta. N Engl J Med. 1996, 334:239. 10.1056/NEJM199601253340406
  5. Georghiou GP, Birk E, Nili M, Stein M, Vidne BA, Erez E: Images in cardiovascular medicine. Direct nail injury to the heart without functional or hemodynamic compromise. Circulation. 2003, 107:e92-3. 10.1161/01.CIR.0000059740.00763.89
  6. Jodati A, Safaei N, Toufan M, Kazemi B: A unique nail gun injury to the heart with a delayed presentation. Interact Cardiovasc Thorac Surg. 2011, 13:363-365. 10.1510/icvts.2011.272120
  7. Madani M, Drissi M, Ajaja MR, et al.: Nail gun may cause heart injury: a young adult's misadventure. Int Emerg Nurs. 2012, 20:98-101. 10.1016/j.ienj.2011.06.006
  8. Nolke L, Naughton P, Shaw C, Hurley J, Wood AE: Accidental nail gun injuries to the heart: diagnostic, treatment, and epidemiological considerations. J Trauma. 2005, 58:172-174. 10.1097/01.ta.0000062972.25842.d5
  9. Prokesch BC, Mangino JE: Nail gun attempted suicide and traumatic ventricular perforations. QJM. 2014, 107:589.
  10. Tuladhar S, Eltayeb A, Lakshmanan S, Yiu P: Delayed presentation of right and left ventricle perforation due to suicidal nail gun injury. Ann Card Anaesth. 2009, 12:136-9. 10.4103/0971-9784.53448
Case report
peer-reviewed

Self-inflicted Cardiac Injury with Nail Gun Without Hemodynamic Compromise: A Case Report


Author Information

Simon Ho

College of Medicine, University of Central Florida

Bo Liu Corresponding Author

Diagnostic Radiology, Florida Hospital-Orlando

Nicholas Feranec

College of Medicine, University of Central Florida

Florida Hospital-Orlando


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Florida Hospital issued approval.


Case report
peer-reviewed

Self-inflicted Cardiac Injury with Nail Gun Without Hemodynamic Compromise: A Case Report


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Saeed K. Alzghari
January 22, 2017 at 07:30 AM
Saeed K. Alzghari

It is incredible that this patient survived their self-inflicted wound. Great job on the analysis and work-up. This was fascinating indeed!

Case report
peer-reviewed

Self-inflicted Cardiac Injury with Nail Gun Without Hemodynamic Compromise: A Case Report

  • Author Information
    Simon Ho

    College of Medicine, University of Central Florida

    Bo Liu Corresponding Author

    Diagnostic Radiology, Florida Hospital-Orlando

    Nicholas Feranec

    College of Medicine, University of Central Florida

    Florida Hospital-Orlando


    Ethics Statement and Conflict of Interest Disclosures

    Human subjects: Florida Hospital issued approval.


    Article Information

    Published: January 10, 2017

    DOI

    10.7759/cureus.971

    Cite this article as:

    Ho S, Liu B, Feranec N (January 10, 2017) Self-inflicted Cardiac Injury with Nail Gun Without Hemodynamic Compromise: A Case Report. Cureus 9(1): e971. doi:10.7759/cureus.971

    Publication history

    Received by Cureus: October 07, 2016
    Peer review began: December 07, 2016
    Peer review concluded: January 03, 2017
    Published: January 10, 2017

    Copyright

    © Copyright 2017
    Ho et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    License

    This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Pneumatically powered nail guns have been used in construction since 1959. Penetrating injuries to the heart with nail guns have a wide range of presentations from asymptomatic to cardiac tamponade and exsanguination. Mortality related to cardiac nail gun injuries is similar to knife injuries, estimated at 25%. Surgical exploration is the treatment of choice. We describe a case of self-inflicted nail gun injury to the chest without hemodynamic compromise in a 51-year-old man. Computed tomography (CT) imaging confirmed nail penetrating the right ventricle, with the tip adjacent to but not violating the abdominal aorta. The patient was successfully treated with thoracotomy and foreign body removal.

Introduction

Pneumatically powered nail guns have been used in construction since 1959. Low-velocity nail guns are primarily used on wooden surfaces while their high-velocity counterparts drive nails into concrete or metal. In the medical literature, nail guns have mostly been described causing orthopedic injuries of the non-dominant arm. However, life threatening cardiac injuries have also been reported, especially self-inflicted cases [1]. Penetrating injuries to the heart with nail guns have a wide range of presentations from asymptomatic to cardiac tamponade and exsanguination. Mortality related to cardiac nail gun injuries is more similar to knife injuries than gunshot injuries, estimated at 25% [1]. Surgical exploration is the treatment of choice [2-10]. However, conservative management has been reported successful in asymptomatic cases [1]. We describe a case of self-inflicted nail gun injury to the chest without hemodynamic compromise in a 51-year-old man. Informed consent was obtained from the patient for this study.

Case Presentation

A 51-year-old white man with past medical history of depression and multidrug abuse presented to our emergency department with altered mental status and complaining of chest pain. Limited history suggested the patient was binge drinking and discharged a nail gun into his chest in a suicide attempt. However, the resulting chest pain became unbearable causing him to call a friend for transport to the emergency department. Past medical history included major depressive disorder, alcohol, tobacco and cocaine abuse, and chronic obstructive pulmonary disease (COPD). Investigations into his social history suggested his wife had died six months ago and he had been abusing alcohol, tobacco, cocaine, and marijuana heavily since. Vital signs did not suggest hemodynamic compromise: pulse was 93 bpm, blood pressure was 100/60 mmHg, and respirations were at 14 breaths/minute. The examination revealed that he was an overweight white man, weighing 75 kg and measuring 178 cm in stature. The patient was alert, although confused. A head exam showed temporal wasting and poor dental health. The pulses in the extremities were diminished but palpable, and carotid upstrokes were felt bilaterally. One puncture wound at the right sternal border between the fourth and fifth ribs was present. Additionally, the patient had decreased capillary refill and increased AP diameter. The rest of the physical exam including the cardiac and pulmonary exam were normal.

Laboratory investigations showed an elevated WBC count at 13,000/mcL and ethanol serum level at 156 mg/dL. Otherwise, his complete blood count, metabolic panel, and liver function tests were normal. Chest X-ray (Figures 1-2) and computed tomography (CT) of the chest (Figures 3-5) revealed a three-inch tapered foreign body consistent with a nail, with the tip adjacent to the abdominal aorta. The tail end of the nail was located within the right ventricular wall. Remarkably, he was not hemodynamically compromised and consented to immediate surgery for removal of the nail.

 
 

 

 
 
 

An intraoperative transesophageal echocardiogram confirmed the location of the nail and normal physiologic cardiac function. A median sternotomy was performed. The patient was found to have extensive pericarditis, and dissection down to the heart was required. The nail had punctured entirely through the anterior right ventricular wall, left atrium, the diaphragm, and into the abdomen, with the tail end remaining in the posterior right ventricular wall. Removal of the nail and closure of the two heart wounds and diaphragm with Prolene® Suture (Ethicon, NJ, USA) was uncomplicated. The chest was closed following the placement of two pacing wires and thoracostomy tube. Postoperative echocardiogram showed no physiologic changes from prior to removal of the foreign body. The patient did well and was extubated immediately following surgery. The patient was held for psychiatric evaluation, but was eventually discharged on postoperative day 8.

Discussion

In the majority of cases, penetrating cardiac trauma occurs secondary to gunshot or stab wounds with reported mortality rates of 60–93% and 22–62%, respectively. Nail gun wounds are much rarer, and one case series has suggested the mortality to be close to 25%. This may be due to the smaller impact behind the projectiles relative to guns and the small frontal cross-sectional area, which focuses impact on a point. Indeed, we find several other reports similar to ours in which a patient suffering chest penetration from a nail gun, regardless of intention, had asymptomatic or delayed presentation [3, 5-6, 8, 10]. This is not to say that nail gun injuries are benign, as penetrating chest injury by nail gun has also led to catastrophic hemodynamic insufficiency [2, 4, 7, 9]. The wide range of presentations is likely due to the nail guns’ wide range of muzzle energies, lack of stabilization, and poor accuracy.

Surgery is the accepted treatment regardless of hemodynamic stability. Unstable patients should be taken immediately to the operating room. More stable patients can receive imaging such as routine chest radiograph or CT scan to help diagnose complications such as hemothorax, hemopericardium, pneumopericardium, and others [7]. CT should only be attempted on stable patients, but is particularly useful in reconstructing the track of the penetrating object and possible migration. Intraoperative transesophageal echocardiogram has been reported to be helpful in guiding surgical treatment [7, 10]. In this case, the patient was stable enough to undergo preoperative imaging, which helped guide operative therapy.

Conclusions

Nail gun injuries to the heart, while rare, are potentially fatal and need immediate evaluation and treatment. In most cases, diagnosis can be made with history and detailed physical exam. Hemodynamically unstable patients should be operated on immediately, while imaging on stable patients can assist in the diagnosis of the penetrating agent and further complications. A CT investigation is particularly helpful in the determination of the projectile track. All patients should be considered for surgery regardless of stability. In our case, the patient was fortunate to have missed his own abdominal aorta, other great vessels, or cardiac valves, which may have led to his demise.

References

  1. Vosswinkel JA, Bilfinger TV: Cardiac nail gun injuries: lessons learned. J Trauma. 1999, 47:588-590. 10.1097/00005373-199909000-00032
  2. Beaver AC, Cheatham ML: Life-threatening nail gun injuries. Am Surg. 1999, 65:1113-6.
  3. Carr CS, Alkhafaji S, Alkhulaifi AM: Penetrating cardiac nail gun injury. Emerg Med J. 2008, 25:313. 10.1136/emj.2006.040121
  4. Felner JM: Images in clinical medicine. Nail in the aorta. N Engl J Med. 1996, 334:239. 10.1056/NEJM199601253340406
  5. Georghiou GP, Birk E, Nili M, Stein M, Vidne BA, Erez E: Images in cardiovascular medicine. Direct nail injury to the heart without functional or hemodynamic compromise. Circulation. 2003, 107:e92-3. 10.1161/01.CIR.0000059740.00763.89
  6. Jodati A, Safaei N, Toufan M, Kazemi B: A unique nail gun injury to the heart with a delayed presentation. Interact Cardiovasc Thorac Surg. 2011, 13:363-365. 10.1510/icvts.2011.272120
  7. Madani M, Drissi M, Ajaja MR, et al.: Nail gun may cause heart injury: a young adult's misadventure. Int Emerg Nurs. 2012, 20:98-101. 10.1016/j.ienj.2011.06.006
  8. Nolke L, Naughton P, Shaw C, Hurley J, Wood AE: Accidental nail gun injuries to the heart: diagnostic, treatment, and epidemiological considerations. J Trauma. 2005, 58:172-174. 10.1097/01.ta.0000062972.25842.d5
  9. Prokesch BC, Mangino JE: Nail gun attempted suicide and traumatic ventricular perforations. QJM. 2014, 107:589.
  10. Tuladhar S, Eltayeb A, Lakshmanan S, Yiu P: Delayed presentation of right and left ventricle perforation due to suicidal nail gun injury. Ann Card Anaesth. 2009, 12:136-9. 10.4103/0971-9784.53448

Community Discussion

Saeed K. Alzghari
January 22, 2017 at 07:30 AM
Saeed K. Alzghari

It is incredible that this patient survived their self-inflicted wound. Great job on the analysis and work-up. This was fascinating indeed!

Simon Ho

College of Medicine, University of Central Florida

Bo Liu

Diagnostic Radiology, Florida Hospital-Orlando

For correspondence:
bo.liu.md@flhosp.org

Nicholas Feranec

College of Medicine, University of Central Florida

Simon Ho

College of Medicine, University of Central Florida

Bo Liu

Diagnostic Radiology, Florida Hospital-Orlando

For correspondence:
bo.liu.md@flhosp.org

Nicholas Feranec

College of Medicine, University of Central Florida