Accidental Nail Gun Penetration to Right Ventricle: A Case Report-Juniper Publishers
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF CARDIOLOGY & CARDIOVASCULAR THERAPY
Introduction: Penetrating cardiac
injuries are life-threatening conditions that require urgent surgical
intervention, and often associated with a high mortality rates. Work
site injuries by nail-gun are present, and although usually involve the
limbs, penetrating cardiac injuries can occur.
Case presentation: We report a case
of a 21 years old carpenter who accidentally shot himself with a nail
gun. An emergent chest computed tomography was done and revealed a nail
penetrating the right ventricle with massive haemopericardium. Median
sternotomy was performed, followed by nail removal and repair of the
right ventricular wound. He had an uncomplicated postoperative course
and was discharged 7 days postoperatively.
Conclusion: Cardiac nail gun
injuries are rare conditions but fatal. They require emergent convenient
surgery, and timing of intervention should be considered to obtain best
outcomes.
Introduction: Penetrating cardiac
injuries are life-threatening conditions that require urgent surgical
intervention, and often associated with a high mortality rates. Work
site injuries by nail-gun are present, and although usually involve the
limbs, penetrating cardiac injuries can occur.
Introduction
The incidence of accidental injuries of nail guns is
increasing, as these devices can be obtained easily and in turn used
with minimal experience and training [1]. Although, most of these
injuries usually involve the limbs [2], a small proportion of
penetrating cardiac injuries have been reported with high morbidity and
mortality rates [3]. Almost all such injuries are in adult men [1].
Moreover, these penetrating injuries can develop cardiac tamponade
particularly during time-consuming examinations as computed tomography
(CT) that leads to hemodynamic instability and more aggravation.
Accordingly,
those patients should be transferred rapidly to the operating room for
emergent surgery [4]. The treatment provided to these injuries is either
median sternotomy or antero-lateral thoracotomy, followed by
decompression of the pericardium and repair of the cardiac injury [5].
During his work in January 2017, a 21 years old
carpenter overbalanced and shot himself with a nail gun. The injury was
in the right hemithorax at the level of 4th intercostal space 1cm
lateral to the right of midline, and appeared as a small, lightly
bleeding wound.
The patient was delivered to our emergency center
collapsed, as he was hypotensive (51/39), tachycardic (163)
with prominent jugular veins. Immediate resuscitation (central
venous access, perfusion with blood products) was done by the
anaesthesia team that stabilizes the condition and enabled CT
scan, which showed a penetrating cardiac injury with retained
fired nail and massive haemopericardium Figure 1. Sudden
circulatory collapse occurred presented with hypotension,
progressive bradycardia, and congested neck veins, so the
patient was taken immediately to the operating room.
Median sternotomy performed, followed by pericardiotomy
to evacuate massive amount of blood and clots from the
pericardial sac. Haemodynamics improved as soon as we opened
the tense pericardium, and circulatory failure was overcome, but
sinus tachycardia began. Inspection of the surgical field revealed
a nail penetrating the anterior surface of the right ventricle.
The nail removed simply and the myocardium repaired with
3-0 pledgetted Prolene transverse mattress sutures without
using cardiopulmonary bypass. Intraoperative transesophageal
echocardiography confirms no valvular or septal injury. A chest
tube (32 French) was left retrosternal followed by sternal
closure.
Postoperatively, the patient was given antibiotics for 6 days
to prevent potential infection from foreign material, and after
smooth recovery course, the patient was discharged home on
the 7th postoperative day.
Nail guns are one of the most commonly used devices in the
construction industry, as they have the power to force a nail into
wood, brick, or even concrete surfaces rapidly and easy. Although
their injuries are predominantly involving the extremities, few
cases of cardiac injury were reported, and they are potentially
fatal carrying about 25% risk of death [1]. This, may owing to
failure of primary diagnosis, as these injuries usually presented
as small penetrating wound with unrecognizable foreign
body, besides no classical signs of tamponade that lead to an
underestimation of the cases [6], and that was in consisting with
our experience.
As in other penetrating cardiac injuries, pericardial
tamponade may develop; at first it is life-saving, but turns
over time to be fatal, due to cardiac failure, especially when
decompensation no longer responds to volume supply. In these
emergent setting, bedside sonographic assessment is valuable
for evaluation of contractility and pericardial effusion [7]. On
the other hand, if patient is hemodynamically stable, CT withcontinuous monitoring should be performed, as done with our
patient to accurately detect the site of the nail and the extent of
injury [2].
Treatment of nail gun injuries mostly requires emergency
operation. Either median sternotomy or anterolateral
thoracotomy can be performed depending on the site of injury,
aiming to relief the tamponade and surgical repair of the wound.
Besides to surgery, fluid resuscitation is critical [7]. In rare
cases, cardio pulmonary bypass may be needed, if other cardiac
lesions, as; septal defects or heart-valve injuries are present [2].
In conclusion, although cardiac nail gun injury is rare, it
can occur and are survivable. This case demonstrates that
physical examination has a significant role in prompt diagnosis,
with special attention to chest wall examination. Moreover, CT
scanning is mandatory to identify the nail site exactly, extent of
injury, and the presence of haemopericardium that may develop
tamponade. Our experience with such these cases reveals that
right ventricle is commonly involved due to its anterior position,
and the key to survival is the accurate recognition of the nature
of the injury, and the timing of surgical intervention.
Written informed consent was obtained from the patient for
publication of this case report and accompanying images.
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