Delayed presentation of a pneumatic nail gun injury to the right ventricle without circulatory compromise

Abstract

Delayed presentation of penetrating cardiac injuries is exceedingly rare due to the observed near 100% pre-hospital mortality. We describe a case of a patient who presented for evaluation nearly 24 h after sustaining a self-inflicted pneumatic nail gun injury to the right ventricular outflow tract. Remarkably, the patient had no evidence of hemodynamic compromise. This case highlights the importance of maintaining a high index of suspicion for cardiac injury with penetrating trauma to the cardiac box regardless of presenting signs and symptoms, and the value of adhering to advanced trauma life support principles.

Penetrating cardiac trauma caused by a nail-gun: A case report and narrative review

“…Those who were unstable were due to pericardial effusion causing tamponade. A few cases describe a delayed presentation, up to 24 h after injury [22] , [23] . Bargoud et al hypothesized that the annular ribbing found on nails provides a nidus for platelet aggregation, especially when a low-pressure chamber such as the right ventricle were affected, effectively tamponading the bleeding [22] .…”

“…Presentations vary from chronic to acute, and from stable to unstable [8] , [12] , [22] , [23] . Some patients have had missed injuries, and present with complications years later [8] .…”

Delayed Presentation of Nail Gun-Associated Traumatic Pneumothorax with a Retained Foreign Body: A Case Report

“…Pneumatic nail guns can propel a nail at approximately 150 ft/second, and abdomen and thoracic injuries represent up to 60% of related fatalities [ 4 ]. These injuries should always elicit a high suspicion for serious injury and careful evaluation per the Advanced Trauma Life Support protocol and Western Trauma Association Guidelines on penetrating chest trauma [ 5 – 7 ]. Upon presentation of a patient with thoracic pneumatic nail gun injury, the differential diagnosis should include traumatic pneumothorax, tension pneumothorax, hemopneumothorax, retained foreign body, mediastinal injury, and vessel injury.…”

“…Few other case reports exist with isolated lung injuries caused by pneumatic nail guns, owing to the rarity of these injuries [ 8 ]. In similar reports with lung or cardiac injuries, delayed presentation was not uncommon and operative intervention was also required [ 7 – 9 ]. In an unstable patient with nail gun-associated traumatic thorax injury, immediate operative intervention should be done.…”

“…In an unstable patient with nail gun-associated traumatic thorax injury, immediate operative intervention should be done. In a seemingly stable patient with nail gun-associated traumatic thorax injury, further workup with chest X-ray and CT should be done to fully evaluate the extent of injury [ 7 – 9 ]. Using these tools to completely evaluate the extent of the injury and make a diagnosis prior to intervention will better serve the patient and assure the correct exposure and operation is done.…”