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    Abstract
    Introduction
    Case Report
    Discussion
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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 12  |  Issue : 2  |  Page : 136-139
Delayed presentation of right and left ventricle perforation due to suicidal nail gun injury


1 Department of Cardiothoracic Surgery and Cardiology, Cardiothoracic Surgery Unit, New Cross Hospital, Wolverhampton, United Kingdom
2 Cardiology Unit, New Cross Hospital, Wolverhampton, United Kingdom

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Date of Web Publication21-Jul-2009
 

   Abstract 

We describe a case of delayed presentation of attempted suicide with a nail gun that penetrated both the right and left ventricle. Nearly invisible entry point of the nail did not reflect the gravity of the injury. A prompt and accurate history along with chest X-ray and bedside transthoracic echocardiography facilitated localization of the nails and helped assess the damage. Despite cardiac arrest after induction of general anesthesia, the patient had a successful outcome. Issues related to the injury site, modalities of investigation and management strategies in a patient with cardiac tamponade are discussed.

Keywords: Cardiopulmonary bypass, echocardiography, injury

How to cite this article:
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

How to cite this URL:
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 [serial online] 2009 [cited 2020 Apr 4];12:136-9. Available from: http://www.annals.in/text.asp?2009/12/2/136/53448



   Introduction Top


High-pressure nail guns have been used in industry since 1950s and are readily obtainable. Inappropriate uses leading to cardiac injuries have been documented. [1],[2] Mortality rates have been noted to be as high as 40% when the injury is self inflicted. [3] Chest X-ray or CT scan have been described as ideal imaging techniques. [4],[5],[6] However, bed side transthoracic echocardiography imaging can delineate the structural and functional status of an injured heart with minimum delay. Despite the time constraint, a well organized strategy of optimal and accurate bedside imaging, efficient resuscitation, prompt cardiopulmonary bypass and surgery provides the opportunity for successful outcome.


   Case Report Top


A 49 year old man presented to casualty with chest and left shoulder pain. He attempted suicide 24 hours ago by firing a high-pressure nail gun into his precordium twice, at point blank range.

On admission, he had a blood pressure of 90/60 mmHg, a heart rate of 110/min and cool peripheries and a respiratory rate of 24/min. Examination revealed two pinpoint blood clots near the xiphisternum with no visible nails [Figure 1]a.

ECG showed 1.5mm ST elevation in the inferio-lateral leads. Cardiac troponin I was elevated at 0.28 micrograms/L. Chest X-ray AP view revealed foreign bodies consistent with two nails overlying the cardiac shadow [Figure 1]b. A lateral film showed that one nail traversed deeply in the horizontal plane at the level of the ventricle, whilst the other was running obliquely upwards at 45 degrees adjacent to the diaphragm. An immediate bedside transthoracic echocardiography was thus performed. This showed a pericardial effusion measuring 1.5cm and an echo-dense nail trajectory traversing from the right ventricle, through the septum and penetrating the left ventricle [Figure 1]c. All valves were found to be normal.

He became progressively hypotensive despite intravenous fluid administration. An internal jugular vein line and arterial line were inserted under local anesthesia in the operating theatre. Induction of general anesthesia was then carried out with intravenous administration of ketamine 0.5mg/kg, phentanyl 100 µg and rocuronium 1mg/kg. Maintenance anesthesia was with isoflurane, morphine and propofol and a 50% mixture of oxygen and air. A trans-esophageal echocardiography (TEE) was attempted following induction but did not provide any clearer pictures.

Immediately following sternotomy, the patient had severe low cardiac output and subsequently developed cardiac arrest due to ventricular fibrillation. Expedited surgical exposure revealed tense hemo- pericardium, which was opened. Brisk bleeding from the inferior surface of the left ventricle was uncontrollable with digital pressure. Open cardiac massage was commenced and the heart was internally defibrillated. Although rhythm was restored, there was no effective output. Purse string sutures were placed while the open cardiac massage was being continued. Right atrium to aorta cardiopulmonary bypass was finally instigated and the patient was cooled to 32°C.

Two nails were found. The first was embedded in the rectus insertion to the xiphisternum and was removed during the sternotomy procedure. The diameter of the head and tail end were only different by 2 mm [Figure 1]d. The second nail was found exiting through the inferior surface of the left ventricle 1cm lateral to the posterior descending artery, causing profuse bleeding [[Figure 2] black arrow]. The entry point of the nail was demarcated by a hole in the right ventricular free margin near the diaphragmatic angle [[Figure 2] white arrow]. Knowing that the two ends were nearly similar, the nail was carefully removed by traction at the exit site of the empty beating heart. Both entry and exit wounds were repaired with 4/0 polypropylene and buttressed with pericardium. Bioglue was also applied.

Intra-operative TEE did not show any residual ventricular septal defect or valvular abnormalities along with good contractility. The patient thus came off cardiopulmonary bypass in sinus rhythm with a small dose (0.02µg/kg/min) of noradrenaline. He made an uneventful recovery and was transferred to the ward on the second post-operative day. A routine check transthoracic echocardiography showed good biventricular function with no intra- cardiac abnormalities.


   Discussion Top


Cardiac nail injuries are potentially fatal and a history of pre-cordial nail gun injury alone must be treated gravely. Entry points of nails to the skin can be nearly invisible and give no indication to the degree of internal injury [Figure 1]a. This patient presented further 24 hours after the initial event and then rapidly deteriorated. However, deterioration can occur at any stage by migration of the nail due to cardiac contraction, coughing and diaphragmatic movements.

We believe a quick and non-invasive transthoracic echocardiography is invaluable and should be the definitive investigation of choice when the patient is presenting with poor hemodynamics. Demonstration of pericardial effusion was evidence of cardiac injury. Furthermore, it mapped the nail trajectory and ruled out valve disruption. CT scanning has been used in other reports of nail gun injury. [4],[5] It is an important modality of investigation and would have helped to locate the exact position of the nails more accurately. However, it gives no information on valve function, the artefact rays from a metallic nail may distort images and may delay surgical intervention. A raised troponin level was indicative of myocardial injury especially in the context of a delayed presentation, but should not be used to guide therapy. Coronary circulation was not checked as the patient made a smooth recovery with no further clinical or EKG changes of ongoing ischemia. A lateral chest X ray helped us give the surface depth of the second nail as it was found in the rectus sheath later on. Ideally, it could be removed under local anesthesia because with respiration and coughing, these tend to migrate in any direction and can damage vital organs. Our patient was already on the way to the operating theatre following the quick imaging procedures.

It is to be noted that in a closely monitored hemodynamically stable patient, it is possible to remove superficial foreign body in cardiac tissue without cardiopulmonary bypass. However, this patient already had a few minutes of internal cardiac massage requiring rapid stabilization with extra corporeal circulation. Further cooling to 32° Celsius was also required in an attempt to lessen the possible neurological and myocardial injury. It was not known during the initial stages the extent of injury to the cardiac tissue. Moreover, massaging a heart with an already embedded foreign body can lead to further damage possibly needing repair.

Knowledge of the type of nail gun is useful because the size and shape of the nail can differ. In our case, the head and tail ends were nearly similar [Figure 1]d, which facilitated the nail being extracted from the left ventricle by the tail end without causing damage to the interventricular septum.

Like Straus et al. , [3] we found TEE in the operating theatre helpful in guiding surgical treatment. In their report, following removal of a nail that had impaled the anterior mitral leaflet, no residual residual foreign bodies were found and normal valve function was noted without the need of any repair.

Finally, fluid therapy, used judiciously, may help tide over the crisis as higher filling pressures are needed to augment the cardiac output. However, careful fluid therapy did not prevent rapid hemodynamic deterioration in our patient, probably secondary to the tearing effect of the nail shaft at the left ventricular exit. Nevertheless, a combination of rapid clinical and echocardiography assessment, immediate transfer to theatre with anesthetic resuscitation, readiness for sternotomy prior to induction of anesthesia and prompt establishment of cardiopulmonary bypass, secured survival in this patient without complications.

 
   References Top

1.Stanbridge RD. Self inflicted nail gun injury of the heart and lung: A short report. Injury 1982;14:285-6.  Back to cited text no. 1  [PUBMED]  
2.Catarino PA, Halstead JC, Westaby S. Attempted nail-gun suicide: Fluid management in penetrating cardiac injury. Injury 2000;31:209-11.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Straus JP, Woods RJ, McCarthy MC, Anstadt MP, Kwon N. Cardiac pneumatic nail gun injury. J Thorac Cardiovasc Surg 2006;132:702-3.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Takagi H, Mori Y, Murase K, Hirose H. Nail gun penetrating cardiac injury. Eur J Cardiothorac Surg 2003;23:841.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Eren E, Keles C, Sareyyupoglu B, Bozbuga N, Balkanay M, Yakut C. Penetrating injury of the heart by a nail gun. J Thorac Cardiovasc Surg 2004;127:598.   Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Nφlke L, Naughton P, Shaw C, Hurley J, Wood AE. Accidental nail gun injuries to the heart: Diagnostic, treatment and epidemiological considerations. J Trauma 2005;58:172-4.  Back to cited text no. 6    

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Correspondence Address:
Patrick Yiu
Cardiothoracic Unit, Heart and Lung Centre, New Cross Hospital, Wolverhampton WV10 0QP
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.53448

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