Page 111 - JSOM Spring 2021

FIGURE 1 CT scan of neck. FIGURE 2 CT scan of chest.

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deceptively destructive nail gun injuries can be. Furthermore,
like bullets and other projectiles, nails can cause cavitation to
surrounding tissues, bone, and organs when the nail strikes
human tissue and transfers kinetic energy. 2 is because SOF deployments are often in austere far-forward
locations that are frequently uninhabited by US Armed Forces.
Injuries often occur when the operator misses the intended These locations require construction of not only fighting posi-
surface, the tool becomes accidentally activated, or the hose tions but also living facilities out of buildings of opportunity
becomes disconnected from the tool. From 2006 –2011, there or lack thereof. Furthermore, nonstandard tactical vehicles
have been 151,000 nail gun injuries seen in US emergency and military vehicles require constant maintenance and up-
departments. Although 90% of patients were treated and re- keep, which often require pneumatic power tools. In addition
leased, there have been case reports involving paralytic spinal to trauma, the SOF medic and healthcare provider must be
cord transection, long bone fracture, bowel perforation, blind- prepared to treat construction and power tool-related acci-
ness, liver laceration, hemopneumothorax, cerebral damage, dents, in addition to the sports-related injuries often seen in
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and fatalities. There is even a case report of nail penetrat- deployed setting. This includes medical planning and neces-
ing the heart and thereby requiring cardiopulmonary bypass sary supply chain logistics to have and store tetanus immuni-
surgery. 4 zation and immunoglobulin.

In addition to nail gun projectiles, this injury also highlights This case also highlights and reinforces the importance of
the extreme dangers of compressed air. Piercing the pneumatic treating injuries in a systematic fashion regardless of initial ap-
tube allowed compressed air to insufflate this patient to the pearance or presentation. The SOF medic and provider must
point of air dissecting up to his neck and chest. Air guns and rigorously and thoroughly inspect and treat all injuries via an
hoses are the most common causes of compressed air injuries. algorithm as derived from Tactical Combat Casualty Care –
There are several case reports of eye injuries at construction MARCH or Advanced Trauma Life Support (ATLS). The
sites. Of note, a construction worker accidentally hit his face provider must then reevaluate the patient and interventions
with an air hose nozzle as he was trying to clean wood chips as the patient’s clinical status changes. This patient presented
off his uniform; this resulted in orbital, cervical, mediastinal, with a relatively simple injury, an embedded nail to his hand.
and intracranial emphysema. Furthermore, compressed air The patient downplayed the significance of his injury himself
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can cause death. There is a case report of 40 pounds of air as underwhelming, a “typical construction injury.” His only
pressure from an air nozzle causing a ruptured ear drum and initial complaint was feeling fullness in his throat. He had no
possibly intracranial hemorrhage. There are estimates that dyspnea. His vital signs were stable for the duration of triage
only 4 pounds of direct air pressure can rupture bowel. In ad- and evaluation.
dition, there is a case report of a young construction worker
who accidentally brought an air nozzle close to his mouth The provider can easily anchor on this patient’s extremity in-
while trying to clean dirt off his clothes. He immediately died jury and tunnel vision on the musculoskeletal system at the
from acute respiratory failure. He was later found to have dif- expense of the rest of the body. After a thorough physical
fuse alveolar damage and an acute lung injury. 6 exam, it was only his subcutaneous emphysema that cued the
providers that there was something more systemic underneath
Pneumatic nail guns and compressed air power tools are ubiq- and happening with this patient. It was his hypoxia which
uitous in Special Operations Forces (SOF) deployments. This necessitated the patient’s rapid sequence intubation. Had the

Pneumatic Nail Gun Injury to the Hand | 107