Page 110 - JSOM Spring 2021

Watch Where You Point That

Pneumomediastinum From Pneumatic Nail Gun Injury to the Hand

Jason J. Nam, MD *; William F. Kelly, MD 2
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ABSTRACT
Pneumatic nail guns are hand-held tools used in industrial and in the chest, pneumomediastinum, pneumopericardium, and a
construction settings. Nail guns cause the most trauma with small right pneumothorax (Figures 1 and 2). The community
hospitalization among construction workers. To our knowl- hospital ED placed a right thoracostomy tube as well. There
edge, we report for the first time a case of pneumomedias- was hemostasis at the wound site, so the community ED pro-
tinum from a nail gun injury to the hand. Our patient was viders applied only dressings and no tourniquet. They admin-
a 40-year-old male construction worker who shot a nail gun istered intravenous fluids and tetanus immunoglobulin. He
into his hand. He became acutely dyspneic and was found to required no vasopressors peri-intubation. Given the need for
have a pneumomediastinum due to air insufflation. He later orthopedic trauma consultation, the patient was transferred to
underwent tube thoracostomy and intubation. To our knowl- a Level 1 trauma center 1.5 hours away via ground transport.
edge, this is the first report of pneumomediastinum from a nail At the Level 1 trauma center, orthopedic traumatologists re-
gun injury to the hand. moved the nail and pneumatic tubing successfully and without
incident. The patient also required further irrigation, debride-
Keywords: pneumatic nail guns; pneumomediastinum; nail ment, and pinning of his fractured first and second middle and
gun injury distal phalanges. He was able to be extubated and discharged
several days later after an uneventful intensive care unit (ICU)
hospitalization. Several months later, he followed up with or-
thopedic surgery and has had no lasting consequences from
Background this injury.
Pneumatic nail guns are important in manufacturing and con-
struction due to increased production rates. These tools use Discussion
a great deal of energy to make a nail into a projectile. Most
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nail gun injuries are superficial and tend to affect extremi- The construction industry first used pneumatic nail guns in
ties, but there are documented cases affected brain, eyes, neck, 1959. These tools have become increasingly popular because
1
heart, thorax, spinal cord, bowel, and liver. We report a case of their relative ease of use. They also greatly increase work
of pneumomediastinum from nail gun injury to the hand. efficiency. Because of their ease of use, they are used by con-
struction workers and laypeople alike.
Case Presentation There have been increasing numbers of accidents related to
1
A 40-year-old man presented from a construction site with a these devices as they become more popular. Pneumatic nail
nail extending from his left thumb to his left middle finger. He guns have safety mechanisms. The safety device at end of gun
was alert and oriented with pain in his left arm and mildly dys- muzzle must be depressed before the nail is released. Nail guns
pneic. On exam, a nail had pierced the pneumatic tube with have two trigger systems. A sequential action trigger (SAT)
a section of tubing in between his two digits pinned by the allows the user to release a nail when both the safety tip is
nail. His two digits, first and third, sandwiched a 6-inch sec- depressed and the trigger is squeezed. A contact action trigger
tion of pneumatic tube at the fingertips. The pneumatic tube (CAT) allows the operator to fire multiple nails by squeezing
had since been cut off. This was the patient’s only wound. He the trigger and repeatedly depressing the safety device. Both
suffered no penetrating injuries. There was noticeable crepitus actuation systems can result in injuries. It is believed that our
and subcutaneous emphysema in his left hand extending to his patient had a pneumatic nail gun with a CAT mechanism. This
shoulder and decreased breath sounds in the right lung. While makes sense as a SAT pneumatic nail gun is less likely to have
being evaluated in a community hospital emergency depart- an unintentional discharge. A pneumatic nail gun with a CAT
ment (ED), he became progressively dyspneic. He described a mechanism can “double fire” due to recoil and have uninten-
sensation of fullness in his throat. Due to worsening hypoxia tional nail gun discharge. 2
and impending hypoxic respiratory failure, the patient under-
went rapid sequence intubation. Of note, from initial triage to Nail guns have a shocking amount of force and energy. The
2
intubation, the patient had been in the hospital for less than 30 nail travels up to 1500 km/h. Bone can fracture with pro-
minutes. Imaging showed extensive subcutaneous emphysema jectiles traveling only 215 km/h, so it is not a surprise how
*Correspondence to jason.nam@duke.edu
1 Dr Nam is a physician in the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Hospital
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in Durham, NC. Dr Kelly is a physician in the Department of Medicine, Uniformed Services University of the Health Sciences in Bethesda, MD.
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