Penetrating cardiac injury: the nail gun, a potentially dangerous tool.

A 25-year-old construction worker was installing a window from the inside but bent his upper body to the outside through the window. As he used a nail gun to secure parts to the window sill, the nail gun ricocheted and misfired a nail into his left chest. After evaluation at a peripheral hospital, he was quickly transferred to our tertiary care centre. On initial evaluation he was awake and alert. He had a paper cup carefully taped to the left anterior chest wall. His blood pressure was 100/70 mm Hg, and he had a heart rate of 102 beats/min. Auscultation of the lungs revealed normal air entry bilaterally. His first and second heart sounds were clear, and there was no murmur. Findings on abdominal examination were unremarkable. There was a nail protruding 3 cm from the anterior chest wall in about the sixth left intercostal space 4 cm lateral to the midline. The nail was angled toward the midline and moved synchronously with respiration. Accompanying information indicated that the nail was 10 cm long. Appropriate intravenous access was secured and the patient was transferred to the operating room. The chest was opened through a sternotomy under general anesthesia. The nail could be seen entering the mediastinum abutting the intact left pleura and then penetrating the left anterolateral aspect of the pericardium. The pericardium was carefully opened to reveal a small amount of blood clot and the nail penetrating the anterior wall of the right ventricle. A 4–0 prolene pursestring suture was placed around the nail and tied as the nail was extracted. Two mediastinal drains were inserted, and the chest was closed in the usual fashion. He had an uncomplicated postoperative course