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J Thorac Cardiovasc Surg 2006;132:702-703
© 2006 The American Association for Thoracic Surgery

Brief Communication

Cardiac pneumatic nail gun injury

Jason P. Straus, MDa,d, Randy J. Woods, MDa,d, Mary C. McCarthy, MDa,d,*, Mark P. Anstadt, MDb,d, Nancy Kwon, MDc,d

a Department of Surgery, Wright State University School of Medicine, Dayton, Ohio
b Miami Valley Heart and Lung Surgeons, Dayton, Ohio
c Anesthesia Services Network, Dayton, Ohio
d Miami Valley Hospital Trauma Service, Dayton, Ohio

Received for publication March 12, 2006; accepted for publication April 11, 2006.

* Address for reprints: Mary C. McCarthy, MD, Department of Surgery, Wright State University School of Medicine, Department of Surgery, Suite 7000, Miami Valley Hospital, One Wyoming St., Dayton, Ohio 45409 (Email: mary.mccarthy{at}wright.edu).

Pneumatic nail guns deliver discrete, low-velocity penetrating trauma causing limited injury.1Go Kinetic energy is centered on the nail's advancing tip, and therefore such injuries are similar to stab wounds. This is reflected in the 11% mortality rate after accidental discharges. Mortality rates might, however, exceed 40% when these injuries are self-inflicted.1,2Go In the case presented the patient attempted suicide, shooting himself 17 times in the chest with a pneumatic nail gun. The optimal diagnostic and therapeutic approach to this unusual injury is described.

Clinical Summary

A 62-year-old man shot himself 17 times in the left anterior chest with a pneumatic nail gun. He lost consciousness for several hours; on awakening, he drove to a local hospital. The patient was transferred to a level 1 trauma center for further treatment. He was hemodynamically stable on arrival. Multiple drywall finishing nails were found imbedded in the anterior chest wall. A chest radiograph demonstrated the 2.5-inch nails within the left chest and mediastinum. The initial electrocardiogram was notable for ST-segment elevation in the precordial leads. A chest computed tomographic scan confirmed penetration of the nails into the heart (Figure 1). A small pericardial effusion and a left hemopneumothorax were present.


Figure 1
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  		Figure 1. Computed tomogram of the chest demonstrating nails penetrating the left ventricle. A small pericardial effusion and left hemopneumothorax were present on adjacent images.

 
In the operating room a transesophageal echocardiogram (TEE) was performed. Nails traversed the anterior and lateral ventricular walls; one was present within the left ventricle, and one impaled the anterior mitral valve leaflet (Figure 2). A median sternotomy was performed, and nails were removed from the mediastinum. The patient was then heparinized and started on cardiopulmonary bypass. Nails penetrating the ventricular wall were removed. Next, a left atriotomy was performed, and a nail protruding into the atrium was extracted. The nail perforating the mitral valve leaflet was removed, and repair was not required. After closure of the atriotomy, TEE was used to examine the mitral valve and to confirm there were no remaining foreign bodies within the cardiac chambers. Fibrin sealant was applied to the ventricular wall to seal off small bleeding points from the nail holes.


Figure 2
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  		Figure 2. Transesophageal echocardiogram demonstrating the mitral valve and the nail preventing proper closure of the anterior leaflet. The arrow marks the nail, and the arrowhead marks the anterior leaflet of the mitral valve.

 
Postoperative cardiac function was poor (cardiac index, 1.9 L · min–1 · m–2). TEE revealed significant anterior and inferior hypokinesis. An intra-aortic balloon pump was required to maintain an adequate cardiac output. Amiodarone was used to control frequent premature ventricular contractions. The intra-aortic balloon pump was weaned on the second postoperative day, and inotropic agents were weaned over the ensuing 8 days. The patient gradually improved, and he was transferred to the Veteran's Administration Medical Center for further rehabilitation and psychiatric treatment.

Discussion

Nail gun injuries can be divided into high- and low-velocity types, with the distinguishing speed at 150 m/s. High-velocity guns have an explosive cartridge that directly propels a missile. Low-velocity guns accelerate the projectile indirectly through a piston powered by compressed air. Muzzle energies of these guns range between 100 and 1000 J.1Go

Single cardiac nail gun injuries have been described.1-3Go However, this case report has several unique features. Despite penetration of the chest and heart by 17 nails, the injuries were not lethal. This confirms the paucity of tissue trauma caused by this mechanism. In addition, pneumatic nail gun injuries create a self-sealing puncture wound that permits time for diagnostic evaluation. A specific diagnosis is essential to the development of a therapeutic strategy.4Go A computed tomographic scan localized the nails, but artifacts precluded counting the nails. TEE is valuable for localizing intracardiac foreign bodies, examining valve function, and defining secondary cardiac shunts.3,4Go In this case TEE was an invaluable tool for delineating the intracavitary nails and guiding the operative approach for removal.

The operative approach should also be highlighted. The patient was cannulated for cardiopulmonary bypass before removal of the nails that had penetrated the myocardium. This allowed a margin of safety, should excessive bleeding or cardiac instability occur. A left atrial approach was used to remove the intracardiac nails. This facilitated evaluation and repair of the valve. A chest radiograph should be performed at the conclusion of the operation to ensure complete removal of multiple foreign bodies. Finally, this case was complicated by postoperative cardiac dysfunction. Although the likely cause for this finding was direct cardiac trauma, additional evaluation might be indicated to rule out underlying coronary artery disease and ongoing cardiac ischemia.

This patient with a pneumatic nail gun injury to the heart was successfully treated with cardiopulmonary bypass and nail extraction alone. His initial hemodynamic stability allowed preoperative evaluation and planning of the surgical approach. The treatment of multiple penetrating nail wounds to the heart was successful by using these principles.

References

  1. Vosswinkel J, Bilfinger T. Cardiac nail gun injuries. lessons learned. J Trauma 1999;47:588-590.[Medline]
  2. Eren E, Keles C, Sareyyupoglu B, et al. Penetrating injury of the heart by a nail gun. J Thorac Cardiovasc Surg 2004;127:598.[Free Full Text]
  3. Nölke L, Naughton P, Shaw C, et al. Accidental nail gun injuries to the heart. diagnostic, treatment, and epidemiological considerations. J Trauma 2005;58:172-174.[Medline]
  4. Mollod M, Felner J. Transesophageal echocardiography in the evaluation of cardiothoracic trauma. Am Heart J 1996;132:841-849.[Medline]




This Article
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Right arrow Chest wall

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