AnEMS crew responded to a 32-year-old male weighing approximately220 lbs. They found the patient seated at a kitchen table with a puncture wound to the back of his head. He had attempted to commit suicide by shooting himself with a pressure-powered 22-caliber nail gun. 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 the head. The wound appeared to no longer be actively bleeding, and the patient complained only of weakness and fatigue and denied any pain.
C-spine precautions were taken immediately. The crew applied high-flow oxygen via non-rebreather. Vital signs were stable. Two large-bore IVs were started at a KVO rate. The transport ambulance arrived and assisted with extrication of the patient from the apartment. He was immobilized on abackboard and carried down three flights ofstairs 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 held off on administration when the patient began to vomit, and 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, he was continually assessed for mental status and neurological deficits.
On arrival at the hospital, the crew gave a full report to the emergency department (ED) trauma team. The patient was alert and oriented but was slow at times to respond to questions. Vital signs remained normal and the neurological exam was unremarkable, with the patient able to follow all commands. After initial trauma assessment, the patient was removed from the backboard with the collar in place and taken for a CT scan of his head and cervical spine.
The crew was told that during the CT scan, the patient remained alert and oriented, and responded to questions appropriately. The cervical spine CT was negative, but the brain CT displayed the large, nail-shaped object in the midbrain. The cervical collar was removed and the results were transmitted to hospital neurosurgeons, who 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.
As with any tool, some people will use a power tool for something other than its intended use, causing unusual injuries. And with the advent of the ˙weekend warrior,Ó more injuries have been caused by power tools. Specifically, the Centers for Disease Control and Prevention reports a dramaticincrease in nail gun injuries. From 2001Ï2005,there were 37,000 injuries caused by nail guns. Of those, 40% were to non-construction workers.
Care for these injuries is usually the same as for any patient with an impaled object. If possible, and if the object is still visible, secure the object. If the projectile isn_t visible and is lodged in the skull, there_s no way to secure the object, and the injury is likely more severe. In this case, because of the unknown location of the projectile, preventing head movement was the primary goal.
Multiple reports of self-inflicted intracranial foreign bodies are documented in the literature. The majority of these are reportedly from suicide attempts. Because the entrance wound may be extremely difficult to see, prehospital providers and ED personnel need to be suspicious of a suicide attempt or psychiatric illness when a patient presents with any blood on the head.
Fatality is reported in up to 40% of cases involving penetrating head trauma. Compressed air nail guns, specifically, are reported to fire at up to 425 meters per second and can cause significant brain injury.
After initial standard prehospital trauma assessment for airway, breathing, circulation, disability and exposure, it_s reasonable to place the patient in a cervical collar, especially if any cervical trauma is suspected. High-flow oxygen and large-bore IVs remain the standard of care while initial assessment and spinal immobilization are being completed. A secondary assessment should include a full neurological examination to determine patient deficits. Transport should always be made to a facility with full neurosurgical capabilities.
After four days of observation in the ICU, the patient continued to demonstrate normal vital signs, and 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. Follow-up imaging demonstrated no evidence of pseudoaneurysm.
Although this patient had a good outcome, there were many times this case could have turned for the worse. Even with extensive training, EMTs and paramedics are often exposed to cases we_ve never seen before and may never see again. This is where learning to get back to basics and improvise on the skills we_re taught can make a difference in the outcome of a patient.
Daniel E. Frazier, EMT-P, is a paramedic atRobertWoodJohnsonUniversityHospital inNew Brunswick,N.J., who previously worked within theNew York City 9-1-1 system of Voluntary Hospitals. He has been involved inEMS for 16 years, working as a paramedic for the past 12. He can be reached at firstname.lastname@example.org.
Mark A. Merlin, DO, EMT-P, FACEP, is an assistant professor of emergency medicine and pediatrics at theUniversity ofMedicine and Dentistry of New Jersey-Robert Wood Johnson Medical School. He_s the EMS medical director atRobertWoodJohnsonUniversityHospital and chair of the New Jersey MICU Advisory Board for the Department of Health and Senior Services.
Andreia Marques-Baptista, MD,is the New Jersey EMS/Disaster Medicine Fellow and an emergency medicine physician attending at theUniversity ofMedicine and Dentistry of New Jersey-Robert Wood Johnson Medical School.
Jessica L. Jenkins, BS, MICP,is a paramedic atRobertWoodJohnsonUniversityHos_pital. She started inEMS 11 years ago and recently became a full-time paramedic. She_s currently studying at the graduate level.
1. Center for Disease Control. ˙Nail gun injuries treated in emergency departments United States 2001Ï2005.Ówww.cdc.gov/mmwr/preview/mmwrhtml/mm5614a2.htm
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