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Nail gun penetrating cardiac injury in a young child
Case Report
Nail gun penetrating cardiac injury in a young child Weizhi Zhang, Liang Cao, Shijun Hu, Xiaojie Huang, Yifeng Yang Lancet 2014; 384: 828 Department of Cardiothoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China (W Zhang MD, L Cao MD, S Hu MS, X Huang MS, Y Yang MD) Correspondence to: Dr Yifeng Yang, Department of Cardiothoracic Surgery, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Changsha, Hunan, 410011, China [email protected]
In April, 2014, the 4-year-old daughter of a construction worker was left by herself at a building site, where she was playing with a pneumatic nail gun. She fired a nail into the left side of her chest. She was taken to a district hospital immediately by her parents. On admission at 16:48 she was alert but terrified. Blood pressure was 105/70 mm Hg, and heart rate 110 bpm. Auscultation of the chest showed normal air entry bilaterally and no heart murmur or pericardial rub. There was a nail protruding about 2 mm from the anterior chest wall, at the sixth left intercostal space 1 cm lateral to the midline. ECG was normal. CT scan at 17:14 showed a 3 cm nail penetrating the anterior myocardium of the right ventricle, with associated haemopericardium (figure). She was transferred urgently to our hospital. On admission at 18:12, she was tachypnoeic and distressed. Blood pressure was 75/50 mm Hg, and heart rate 145 bpm. She was immediately taken to theatre and underwent a median sternotomy at 18:35. Her haemodynamic status improved as soon as we opened the tense pericardium. We found a nail penetrating from the anterior surface of the right ventricle to the diaphragmatic surface, with active bleeding at the exit site. We removed the nail and repaired the myocardium without using cardiopulmonary bypass. Intraoperative transoesophageal echocardiography showed no valvular or septal injury. We gave cefotiam for 3 days to prevent potential infection from foreign material. After an uneventful recovery the patient was discharged home on the fifth postoperative day. Injuries from nail guns are increasingly common because these devices are easy to obtain and can be used with minimum training.1 Cardiac injuries represent a small proportion of nail gun injuries, but carry about
A
Figure: Chest CT A 3 cm long nail is shown penetrating the right ventricle.
828
B
25% risk of death. Almost all such injuries are in adult men.1,2 Prevention is key to avoiding nail-gun-associated injuries. Safety mechanisms should be improved, consumers trained, and sales of nail guns restricted. Several approaches have been suggested for management of penetrating cardiac trauma, dependent on the severity of injuries. Tamponade can develop while time-consuming examinations, such as CT scans, are being done. Unstable patients with clear signs of tamponade or haemodynamic instability should be taken immediately to the operating room for urgent surgery, which is the key to survival.3,4 For hypotensive patients with penetrating torso injuries delaying aggressive fluid resuscitation until operative intervention improves outcomes.5 The patient’s status can deteriorate rapidly, as in our case. Interhospital transfers are fraught with danger. Cardiopulmonary bypass is not a requirement for the acute management of penetrating cardiac injury, and best practice should be for the surgery to take place at the admitting hospital. Surgeons at smaller district hospitals might not have experience of this type of surgery and, with the tense doctor–patient relationship in China, this lack of experience can leave district surgeons reluctant to undertake what might be a life-saving procedure. Efforts in China should focus on improved emergency services in which paramedics triage all major traumas directly to specialist trauma centres, as occurs in many other countries. Consideration should also be given to implementation of properly regulated multisite practice, which would allow registered doctors to work in more than one setting, and might encourage doctors to practise medicine in remote and rural areas in China. Contributors All authors looked after the patient. WZ, LC, SH did the operation. WZ and YY wrote the report. Written consent to publication was obtained. References 1 Temple AD, Fesmire FM, Seaberg DC, Severance HW. Cardiac injury due to accidental discharge of nail gun. J Emerg Med 2013; 44: e16163. 2 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. 3 Wang MJ, Chen IS, Tsai SK. Nail gun penetrating injury of the left ventricle and descending aorta. Circulation 1999; 100: e1819. 4 Hsia RY, Mahadevan SV, Brundage SI. Penetrating cardiac injury from a wooden knitting needle. J Emerg Med 2012; 43: 116–19. 5 Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994; 331: 1105–09.
www.thelancet.com Vol 384 August 30, 2014
Nail gun penetrating cardiac injury in a young child Weizhi Zhang, Liang Cao, Shijun Hu, Xiaojie Huang, Yifeng Yang Lancet 2014; 384: 828 Department of Cardiothoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China (W Zhang MD, L Cao MD, S Hu MS, X Huang MS, Y Yang MD) Correspondence to: Dr Yifeng Yang, Department of Cardiothoracic Surgery, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Changsha, Hunan, 410011, China [email protected]
In April, 2014, the 4-year-old daughter of a construction worker was left by herself at a building site, where she was playing with a pneumatic nail gun. She fired a nail into the left side of her chest. She was taken to a district hospital immediately by her parents. On admission at 16:48 she was alert but terrified. Blood pressure was 105/70 mm Hg, and heart rate 110 bpm. Auscultation of the chest showed normal air entry bilaterally and no heart murmur or pericardial rub. There was a nail protruding about 2 mm from the anterior chest wall, at the sixth left intercostal space 1 cm lateral to the midline. ECG was normal. CT scan at 17:14 showed a 3 cm nail penetrating the anterior myocardium of the right ventricle, with associated haemopericardium (figure). She was transferred urgently to our hospital. On admission at 18:12, she was tachypnoeic and distressed. Blood pressure was 75/50 mm Hg, and heart rate 145 bpm. She was immediately taken to theatre and underwent a median sternotomy at 18:35. Her haemodynamic status improved as soon as we opened the tense pericardium. We found a nail penetrating from the anterior surface of the right ventricle to the diaphragmatic surface, with active bleeding at the exit site. We removed the nail and repaired the myocardium without using cardiopulmonary bypass. Intraoperative transoesophageal echocardiography showed no valvular or septal injury. We gave cefotiam for 3 days to prevent potential infection from foreign material. After an uneventful recovery the patient was discharged home on the fifth postoperative day. Injuries from nail guns are increasingly common because these devices are easy to obtain and can be used with minimum training.1 Cardiac injuries represent a small proportion of nail gun injuries, but carry about
A
Figure: Chest CT A 3 cm long nail is shown penetrating the right ventricle.
828
B
25% risk of death. Almost all such injuries are in adult men.1,2 Prevention is key to avoiding nail-gun-associated injuries. Safety mechanisms should be improved, consumers trained, and sales of nail guns restricted. Several approaches have been suggested for management of penetrating cardiac trauma, dependent on the severity of injuries. Tamponade can develop while time-consuming examinations, such as CT scans, are being done. Unstable patients with clear signs of tamponade or haemodynamic instability should be taken immediately to the operating room for urgent surgery, which is the key to survival.3,4 For hypotensive patients with penetrating torso injuries delaying aggressive fluid resuscitation until operative intervention improves outcomes.5 The patient’s status can deteriorate rapidly, as in our case. Interhospital transfers are fraught with danger. Cardiopulmonary bypass is not a requirement for the acute management of penetrating cardiac injury, and best practice should be for the surgery to take place at the admitting hospital. Surgeons at smaller district hospitals might not have experience of this type of surgery and, with the tense doctor–patient relationship in China, this lack of experience can leave district surgeons reluctant to undertake what might be a life-saving procedure. Efforts in China should focus on improved emergency services in which paramedics triage all major traumas directly to specialist trauma centres, as occurs in many other countries. Consideration should also be given to implementation of properly regulated multisite practice, which would allow registered doctors to work in more than one setting, and might encourage doctors to practise medicine in remote and rural areas in China. Contributors All authors looked after the patient. WZ, LC, SH did the operation. WZ and YY wrote the report. Written consent to publication was obtained. References 1 Temple AD, Fesmire FM, Seaberg DC, Severance HW. Cardiac injury due to accidental discharge of nail gun. J Emerg Med 2013; 44: e16163. 2 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. 3 Wang MJ, Chen IS, Tsai SK. Nail gun penetrating injury of the left ventricle and descending aorta. Circulation 1999; 100: e1819. 4 Hsia RY, Mahadevan SV, Brundage SI. Penetrating cardiac injury from a wooden knitting needle. J Emerg Med 2012; 43: 116–19. 5 Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994; 331: 1105–09.
www.thelancet.com Vol 384 August 30, 2014