Background
Nail gun related injuries are becoming more common1,2. Intracranial injuries remain a rare subset, accounting for less than 0.1% of nail gun injuries3. To date, there have been approximately 45 reported cases in the literature concerning penetrating nail gun injuries to the head7. Overall, these patients have favorable outcomes, although there have been reports describing devastating neurologic deficits and death1,4.
These patients pose unique challenges to anesthesia providers, highlighting the importance of a multidisciplinary approach and strategic planning.
Case Description
A 28-year-old man was accidentally struck in the head with a nail from a pneumatic nail gun at close range. On outside imaging, the nail appeared to lacerate the lateral aspect of the superior sagittal sinus. Based on this, the patient was transferred to Zuckerberg San Francisco General Hospital (ZSFGH) for higher level of care.
On arrival to ZSFGH, the patient was hemodynamically stable, and alert and oriented. Exam was significant for left homonymous hemianopsia with intact CN III-XII. CT head revealed an 8 cm nail penetrating his occipital bone, traversing the right occipital and parietal lobes with mild multi-compartmental hemorrhage. CT angiogram and venogram revealed the tip of the nail abutting the posterior superior sagittal sinus without evidence of active extravasation.
Given the potential for massive blood loss and neurologic injury, a multidisciplinary team consisting of neurosurgery, anesthesia, and radiology was gathered to devise a detailed management plan.
A CT scanner was reserved for immediate scanning of our patient. The patient was brought to the operating room (OR) and standard ASA monitors were applied. A rapid infusion device and blood products were in the room. He underwent rapid sequence induction and was intubated with a 7.5 endotracheal tube. A radial arterial line was placed for hemodynamic monitoring. A large-bore central catheter was inserted into the left subclavian vein. Given the proximity of the nail to vital draining veins, the patient was prepped and draped for possible craniotomy.
The surgical team carefully extracted the nail with a vice grip. There was a small amount of venous bleeding which ceased spontaneously. The patient was hemodynamically stable throughout. He remained intubated and was transported to the CT scanner for repeat imaging, which revealed unchanged mild multi-compartmental intracranial hemorrhage and no active extravasation. The patient was transported to the ICU. He was extubated the following day with persistent left homonymous hemianopsia, but otherwise neurologically intact.
Discussion
This case emphasizes the responsibility of anesthesiologists to maintain close communication with multi-disciplinary teams in anticipation of all possible clinical outcomes, a quality that contributed greatly to this patient’s positive outcome. Given the complexity of this case, we anticipated the need to have in place a step-wise approach to management. In discussion with colleagues in neurosurgery, nursing, and radiology, we devised a detailed plan for each critical step and downstream consequence. This multidisciplinary approach to patient care lends its benefit to numerous clinical scenarios and should be applied to urgent traumatic events whenever feasible.
