Editor_s note:The following scenario appeared in expanded form as a Case of the Month in theNovember issue of JEMS.The photos in this slideshow further depict the nail implanted in the patient's skull as well as its removal.
An EMS crew responded to a 32-year-old male weighing approximately 220 lbs. The patient had attempted to commit suicide by shooting himself with a pressure-powered 22-caliber nail gun. Most nails accidentally shot into the head will stop with the head of the nail in against the skull, but because this was self-inflicted, with the gun pressed against the head, there was no slowing of the projectile in the air. The nail that entered the patient_s skull was 2" long.
On assessment, a small entrance wound was found directly in the center of the back of his head. The wound appeared to no longer be actively bleeding, and the patient complained only of weakness and fatigue and denied any pain.
The crew took C-spine precautions and applied high-flow oxygen via non-rebreather. Vital signs were stable. Two large-bore IVs were started at a KVO rate. The patient was immobilized on a backboard and carried down three flights of stairs to the ambulance.
En route to the trauma center, the patient was able to maintain his own airway. Crew members postponed intubation in order to assess potential neurological deficits. During assessment, the patient became slightly combative and uncooperative. Orders for Ativan were obtained, but medics put off administration when the patient began to vomit, at which they re-contacted medical consult.
The crew maintained the patient_s airway through suctioning and by positioning the patient on his left side while he was still immobilized. During transport, the patient was continually assessed for mental status and neurological deficits.
At the hospital, the cervical collar was removed, a CT scan was taken, and hospital neurosurgeons decided to observe the patient secondary to risk of mortality without immediate surgical removal. The patient was admitted, and a cerebral angiogram demonstrated normal vasculature and no evidence of traumatic cerebral aneurysm.
Removal of the nail can be accomplished by craniotomy or removal under sedation via local manipulation. Local nail removal is typically accomplished while the patient is awake or partially sedated. Risks associated with a sudden increase in intracranial pressure are seizure, herniation, edema, hypertension and aneurysm rupture.
After four days of observation in the surgical ICU, the patient continued to demonstrate normal vital signs and the neurosurgeons decided to remove the nail surgically with local anesthetic. Within three hours, the patient was extubated with no neurologic deficits and discharged with psychiatric follow-up advised. The patient did remarkably well with no neurologic deficits to date.