Traumatic cardiac injury by gun nails.

Sir,

A 40-year-old man presented himself at the Emergency Department after being shot five times by a nail-gun during a robbery. Upon arrival at the Emergency Department the patient had an optimal Glasgow Coma Scale score and was in stable hemodynamic and respiratory condition. Chest X-ray [Figures 1 and 2] showed five corpora aliena perforating the sternum and probably the heart. The ECG showed no abnormalities. Shortly after, the patient's hemodynamic condition deteriorated slowly.

Figure 1

Chest X-ray, PA, showing the position of the gun nails

Figure 2

Chest X-ray, LAT, showing the position of the gun nails

Immediate transfer to the operating theatre followed and an emergency thoracotomy was performed, since a cardiac tamponade was suspected. By opening the pericardium an amount of blood was released improving the hemodynamic condition. Exploration showed that the left ventricle was perforated by one nail just next to the Left Anterior Descending coronary artery (LAD) and four nails perforated the right ventricle. The nails were removed one by one and the wounds were sutured. The postoperative period was uncomplicated. On day seven the patient was discharged from the hospital. Shortly after discharge, a coronary angiography was performed and showed no abnormalities or injuries.

Massive blood loss is usually prevented in case of penetrating cardiac trauma, because the solid object seals off the entry wound.[1] These patients have a high incidence (80-90%) in developing a cardiac tamponade. A normal cardiac silhouette on the chest X-ray does not exclude this. Classic symptoms like pulsus paradoxus or inspiratory jugular venous distention (Kussmaul sign) can be present.[2] Cardiac ultrasound may quickly confirm the presence of increased pericardial fluid.[3]