|Year : 2019 | Volume
| Issue : 1 | Page : 46-48
Emergency department presentation of hemoptysis due to nail gun injury
Huseyin Narci1, Seda Ozer1, Gülten Bozali1, Cüneyt Ayrık1, Ali Ozdülger2
1 Department of Emergency Medicine, Faculty of Medicine, Mersin University, Mersin, Turkey
2 Department of Thoracic Surgery, Faculty of Medicine, Mersin University, Mersin, Turkey
|Date of Web Publication||8-Mar-2019|
Dr. Huseyin Narci
Department of Emergency Medicine, Mersin University, Faculty of Medicine, Mersin
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Nail guns are cheap and easy-to-access devices that are common in the industry and personal use and are widely used by untrained people. Life-threatening injuries may occur after a self-accident due to the use of these devices. We report the case of a 47-year-old man who had hemoptysis due to a lung parenchymal injury after nail gun use. Computed tomography revealed focal alveolar hemorrhage. Hemodynamically stable, the patient underwent surgery. Nail guns penetrating the chest can cause life-threatening situations. In the emergency department, rapid diagnosis and treatment is vital in preventing fatal outcome.
Keywords: Alveolar hemorrhage, hemoptysis, nail gun
|How to cite this article:|
Narci H, Ozer S, Bozali G, Ayrık C, Ozdülger A. Emergency department presentation of hemoptysis due to nail gun injury. Int J Crit Illn Inj Sci 2019;9:46-8
|How to cite this URL:|
Narci H, Ozer S, Bozali G, Ayrık C, Ozdülger A. Emergency department presentation of hemoptysis due to nail gun injury. Int J Crit Illn Inj Sci [serial online] 2019 [cited 2020 Feb 21];9:46-8. Available from: http://www.ijciis.org/text.asp?2019/9/1/46/253766
| Introduction|| |
Nail guns are easy-to-access and cheap devices that are frequently used in the construction and wood industries. They are often used by many untrained people. Although the most frequent hand injuries are due to nail guns, thorax, abdomen, pelvis, facial bones, and skull injuries have also been reported. Injuries often occur in the industrial and nonoccupational environments with a vast majority after self-accidents.,
In the literature, most thoracic cases with nail gun injuries involve cardiac injuries. To the best of our knowledge, this is the first reported case of hemoptysis due to lung parenchymal injury following nail gun injury. This communication aims to document our experience with the management of this patient who developed hemoptysis after thoracic nail gun injury.
| Case Report|| |
A 47-year-old male construction worker was admitted with a history of a nail gun injury to his chest ½ h before. After accidentally falling from the same level, the nail discharged his chest wall, and he had hemoptysis. Hemoptysis was transient and three times. On admission, the hemodynamics was stable; there was no subcutaneous emphysema, and cardiovascular and chest auscultation were normal. There was a nail entry wound to the right of the sternum in the 3rd intercostal space, about 0.5 cm in diameter. The patient's arterial blood pressure was 130/80 mmHg, pulse was 84/min, and O2 saturation was 95%. The patient was monitored, and hemodynamic follow-up was obtained. Tetanus vaccination and parenteral antibiotic therapy were started. Electrocardiogram was normal. An anteroposterior and lateral chest X-ray (CXR) [Figure 1] revealed a metallic object – the nail wire. Computed tomography (CT) of the thorax showed the nail penetrating the lung parenchyma and focal alveolar hemorrhage [Figure 2].
|Figure 1: Anteroposterior and lateral chest radiographs demonstrating nail penetration of the sternum and into the lung parenchyma|
Click here to view
|Figure 2: Computed tomography image of thorax: The nail penetrating the lung parenchyma and focal alveolar hemorrhage|
Click here to view
Subsequently, the patient was referred to the thoracic surgery department. The patient was taken to the operating room, and a 30-mm nail was slowly manipulated and removed via retrograde extraction. There was no complication post surgery. We thought that this kind of penetrating injury might be pneumothorax in CXRs. Pneumothorax, hemothorax, and vascular injury may occur in the patient post extraction of the nail. Therefore, patients should be monitored for at least 24 h and followed by CXR. On the 2nd day of hospitalization, the patient was discharged with normal CXR.
| Discussion|| |
A nail gun is a mechanical device that is used to frame wooden structures, secure the wood, and support concrete and many other construction and home improvement applications. Upper-extremity injuries, especially of the hands and fingers, constitute 75% of all nail gun injuries. Although extremity injuries are most common, life-threatening injuries to the head, neck, chest, abdomen, and pelvis may occur. Paralytic spinal cord transection, bowel perforation, long bone fracture, liver laceration, hemopneumothorax, blindness, cerebral damage, and even fatal injuries have been reported.,
Penetrating thoracic trauma is usually less common but more fatal than blunt chest trauma. Penetrating chest injuries are rarely seen as preventable causes of death. These injuries are caused by 10% of gunshot wounds and 9.5% of stabbings in the United States.,
Lung injuries from penetrating trauma may include pneumothorax, pulmonary contusion, hemothorax, and pulmonary laceration. Pulmonary contusion is a direct bruise leading to alveolar hemorrhage of the lung. Clinical symptoms of pulmonary contusion include dyspnea, hypoxia, tachypnea, and hemoptysis. In our patient, focal alveolar hemorrhage in the lung parenchyma was the cause of hemoptysis. However, pneumothorax, hemothorax, and mediastinal injury did not accompany it.,
Hemodynamically unstable patients should be taken directly to the operating room without diagnostic intervention in the emergency department. In hemodynamically stable patients, imaging techniques such as routine CXR or CT scan should be performed to detect hemothorax, hemopericardium, pneumopericardium, and other complications. A CXR is a valuable and rapid diagnostic tool with appropriate technique and position in case of thoracic penetrant injuries. Computed chest tomography is superior than the CXR in evaluation of lung contusion, hemothorax and mediastinum. In our case, there was no pathology except the nail in the CXR. In order to determine the cause of hemoptysis, we planned a thorax CT for further investigation. CT showed a consistent image of focal alveolar hemorrhage.
Surgical treatment should be considered for all patients regardless of hemodynamic status. Approximately 15% of patients with penetrating thoracic trauma require surgical treatment. Emergency thoracotomy indications include heart tamponade and major bleeding or massive air leakage.,
Nail guns are cheap and easily accessible tools commonly used in the construction and wood industries. Many people often use them without training. Nail guns penetrating the chest can cause life-threatening situations. In the emergency department, quick diagnosis and treatment is important for preventing fatal outcome. Personnel training and safety must be provided to prevent such injuries. Use of such devices by the untrained should be prevented.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pierpont YN, Pappas-Politis E, Naidu DK, Salas RE, Johnson EL, Payne WG, et al.
Nail-gun injuries to the hand. Eplasty 2008;8:e52.
Temple AD, Fesmire FM, Seaberg DC, Severance HW. Cardiac injury due to accidental discharge of nail gun. J Emerg Med 2013;44:e161-3.
Lipscomb HJ, Schoenfisch AL. Nail gun injuries treated in U.S emergency departments, 2006-2011: Not just a worker safety issue. Am J Ind Med 2015;58:880-5.
Beaver AC, Cheatham ML. Life-threatening nail gun injuries. Am Surg 1999;65:1113-6.
Davis JS, Satahoo SS, Butler FK, Dermer H, Naranjo D, Julien K, et al.
An analysis of prehospital deaths: Who can we save? J Trauma Acute Care Surg 2014;77:213-8.
Champion HR, Copes WS, Sacco WJ, Lawnick MM, Keast SL, Bain LW Jr., et al.
The major trauma outcome study: Establishing national norms for trauma care. J Trauma 1990;30:1356-65.
Roscher R, Bittner R, Stockmann U. Pulmonary contusion. Clinical experience. Arch Surg 1974;109:508-10.
Guitron J, Huffman LC, Howington JA, Locicero J. Blunt and penetrating injuries of the chest wall, pleura and lungs. In: Shields TW, Locicero J, Reed CE, Fein RH, editors. General Thoracic Surgery. 7th
ed. Philadelphia: Lippincott Williams and Wilkins; 2010. p. 891-902.
Ho S, Liu B, Feranec N. Self-inflicted cardiac injury with nail gun without hemodynamic compromise: A case report. Cureus 2017;9:e971.
Trupka A, Waydhas C, Hallfeldt KK, Nast-Kolb D, Pfeifer KJ, Schweiberer L, et al.
Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: Results of a prospective study. J Trauma 1997;43:405-11.
Meredith JW, Hoth JJ. Thoracic trauma: When and how to intervene. Surg Clin North Am 2007;87:95-118, vii.
[Figure 1], [Figure 2]