Low-Velocity Nail-Gun Injuries to the Interventricular Septum: Report of Two Cases, One in a Child

Abstract

Nail-gun injury to the heart is rare. Nail-gun N ail-gun injury to the heart is rare. Nail guns usually cause injuries to the extremities. To the best of our knowledge, there have been only 5 reported cases of penetration of the cardiac interventricular septum (IVS), and none of those has involved a child. 1-5We describe 2 additional cases of nail-gun injuries through the IVS. One case involved an accidental self-inflicted wounding of a child, who needed removal of the nail during cardiopulmonary bypass (CPB). In the adult, we used adenosine to slow the heart rate in order to extract 3 nails before performing a median sternotomy to suture entrance wounds in the right ventricle (RV). All nails were removed under transesophageal echocardiographic (TEE) guidance. Case Reports Patient 1In March 2012, a 3-year-old Russian immigrant picked up a pneumatic nail gun and accidentally shot himself in the chest. He walked over to his mother and reported that his chest hurt. His mother noticed a small puncture wound in the left parasternal area and took him in the family car to a local emergency department.Vital signs on arrival were a systolic blood pressure of 128 mmHg, a heart rate of 128 beats/min, a respiratory rate of 20 breaths/min, and pulse oximetry of 98% on room air. Physical examination produced normal results except for a small left parasternal puncture wound in the 5th intercostal space. A portable chest radiograph revealed a nail 3.81 cm in length, penetrating the left chest and possibly entering the left atrium (Fig. 1). The patient was transferred to our trauma center.Upon arrival, the boy was taken directly to the operating room. The patient showed no clinical signs of pericardial tamponade. Under general anesthesia, he underwent an intraoperative TEE, which showed the nail traversing the mid RV, crossing the ventricular septum, and entering the left ventricular (LV) chamber. The tip of the nail lay adjacent to the LV free wall and limited the movement of the mitral valve cord apparatus, causing mild mitral regurgitation. There was a suggestion of a patent foramen ovale.Through a median sternotomy, we performed a pericardiotomy and removed a small amount of dark blood. The head of the nail was not visible. Using two 6-0 Prolene traction sutures, we probed the epicardial entry wound; the nail was too Case Reports

Delayed Pericardial Tamponade after Nail Gun Injury to the Right Ventricle

“…Chest computed tomography (CT) scans can be used to confirm the intra-thoracic position of the nail, and to detect pericardial effusion [8]. The stable status of our case at admission gave us the chance to perform preoperative CT and bedside echocardiography [14][15][16][17].…”

Penetrating cardiac trauma

“…Simple extraction of the offending object does however pose further risks of damage to a potentially unstable patient (e.g. a missile that approximates a coronary artery or is deeply embedded within the myocardium and tamponading the wound) [ 39 , 40 ]. Furthermore, manipulation of foreign bodies contained within the left heart require great care and speed due to the high risk of critical embolization [ 41 ].…”

“…Alternatively, purse-string sutures may be placed at the entry site to close the defect immediately after removal. Intravenous adenosine infusion can also be considered as an adjunctive maneuver to lower contractility and facilitate safe extraction of the penetrating object [ 40 ]. The concomitant use of intraoperative transesophageal echocardiography may also be particularly helpful for visualization a bleeding heart, reinforcing assessment of the penetrating body and guiding surgical instruments [ 42 ].…”

Technical considerations in the management of penetrating cardiac injury

“…embedded within the myocardium and tamponading the wound). 39,40 Manipulation of foreign bodies contained within the left side of the heart requires great care and speed owing to the high risk of critical embolization. 41 When removal is indicated, embedded projectiles can be manually extracted with forceps after sewing pled geted, doublearmed, horizontal mattress sutures around the body and slowly tightening the stitches dur ing extraction.…”

“…Intravenous adenosine infusion can also be considered as an adjunctive manoeuvre to lower contractility and facilitate safe extraction of the foreign body. 40 The concomitant use of intraoperative transesophageal echocardiography may also be particularly helpful for visualization of a bleed ing heart, reinforcing assessment of the foreign body and guiding surgical instruments. 42 The decision to institute CPB must be balanced against its risks to the patient, but when appropriate, should be triggered early in the surgical process given its clear benefit of ensuring adequate repair or foreign body extraction.…”