Multiple nail gun injuries: suicide or homicide?

Nail gun injuries are a forensic problem; it can be difficult to distinguish self-inflicted injuries from accident and homicide instances. This kind of injuries shares some characteristics with both gunshot and puncture wounds. We describe a peculiar case of a man who committed suicide driving nails into his skull using a pneumatic nail gun. Entrance wounds were found on both temporal regions of the head. Reviewing scientific literature, this is the first case in Italy reporting the macroscopic data of bilateral head and brain nail gun injuries during an autopsy. Circumstantial elements were not sufficient to clarify if these lesions were self-inflicted, inflicted by accident, or else. Radiological examination can be helpful to show the exact location of the nails, but it has also its own limitations. We firmly believe that autopsy, especially the head section, is crucial to identify the nature and the extension of these lesions, thus giving us much more information about the mechanism of death and the circumstances in which it occurred.

Penetrating craniocerebral nail gun injury in a child: a case report.

Penetrating craniocerebral injuries with a nail gun are extremely rare and even rarer in children. In this case, a 2-year-old boy, who was the youngest patient in the literature with an intracranial nail gun injury involving penetration of the right temporal lobe, was reported. The patient was evaluated by plain radiography and computed tomography. The nail was loosened and pulled gently out by creating a small craniotomy around the nail entrance. Although clinical characteristics and treatment methods of penetrating craniocerebral injuries were similar for reported in literature, the injury mechanism of presented case was different. Penetrating craniocerebral injuries with a nail gun are very dramatic situation, but mortality and morbidity are low. Without major vascular injury, a nail can be removed through a small incision. Penetrating injuries often occur accidentally in the pediatric age group, but the risk of child abuse should always be considered.

Craniocerebral nail gun injuries: a definitive review of the literature.

AIM: Nail guns are important time saving devices but are associated with morbidity and mortality. Specifically, craniocerebral injuries have been reported in the literature since 1963 and have increased in frequency as the use of these tools has become commonplace. There remains a paucity of literature comprehensively assessing nail gun injuries, as compared with other penetrating craniocerebral injuries like those from firearms. METHOD: A literature review of PubMed, Medline (Ovid), Cochrane library, and Google Scholar for articles published between 1960 and 2018 reporting craniocerebral nail gun injuries. RESULTS: In total, 96 individual cases were identified, with 80 meeting inclusion criteria. These were categorized as accidental and intentional injuries. The demographic was overwhelmingly young males (97.5%), and intentional self-inflicted injuries (54%) was the most frequent mechanism of injury. Overall mortality was 10%. Mortality was more common in patients with intentional injuries, but morbidity rates were similar between the accidental and intentional injury cohorts. Post-operative complications rate was 23.8%. CONCLUSION: Craniocerebral nail gun injuries are associated with lower rates of both mortality and residual neurological deficits than craniocerebral firearms injuries. There is limited data to inform clinical prognostication about long-term neurological impairments and the time to recovery which should be addressed in future studies.

Penetrating chest injury afflicting coronary artery fistula-A delayed and asymptomatic occurrence.

We present here a case of a symptomatic chest injury with a nail gun causing a delayed occurrence of coronary artery fistula to the left pulmonary artery presenting with unstable angina 4 years after the initial injury, three of which were symptom-free. The patient underwent successful surgical closure of the fistula and removal of the foreign body.

Management of non-missile penetrating spinal injury.

Review of the literature with case illustration. Non-missile penetrating spinal injury (NPSI) represents a small subset of spinal cord injuries at tertiary trauma centers and is comprised mostly of knife violence. Strict guidelines for the management of penetrating spinal cord injury remain elusive given the variability of mechanisms, rarity of clinical experience, and paucity of prospective studies. A review of the literature was conducted by search of the National Library of Medicine (PubMed) in the English language through June of 2018. Additional articles were culled from the reference lists of the included series. Eleven case series totaling 1007 patients, along with 21 case reports, were identified. In summary, magnetic resonance imaging (MRI) may be beneficial in assessing incomplete or progressive spinal injuries and can be considered with retained foreign bodies in select cases. Forty-eight hours of antibiotic prophylaxis is likely sufficient to prevent infection. Puncture wounds should be debrided, washed, and closed. Retained foreign bodies should be removed in the operating room and often require laminectomy. Early intervention is preferred. Non-missile penetrating spinal injury has a higher likelihood of neurologic recovery as compared to other traumatic spinal injuries.

Bedside Ultrasonography in the Management of Penetrating Cardiac Injury Caused by a Nail Gun.

BACKGROUND: Injuries from nail guns are a unique type of penetrating trauma seen in emergency departments (EDs), rising in prevalence in the United States. These devices can lead to life-threatening injuries that require rapid diagnosis to help guide management. CASE REPORT: An elderly man was brought to the ED having sustained a nail gun injury to the chest. After loss of pulses, brief closed chest compressions and rapid blood product administration led to a return of spontaneous circulation. Using bedside ultrasound, a metallic foreign body was identified tracking through the right ventricle with associated pericardial fluid and pericardial clot. This rapid diagnosis with bedside ultrasound helped facilitate timely transport to the operating room for median sternotomy, foreign body removal, and pledgeted cardiac repair. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With continued developments in image quality and acquisition, and improvements of physician operator performance, ultrasonography has continued to make significant impacts in traumatically injured patients in new ways. We present this case report to highlight precordial nail gun injuries and to emphasize the diagnostic capabilities of bedside ultrasound for these patients.

Penetrating Head Injury by a Nail Gun: Case Report, Review of the Literature, and Management Considerations.

Our objective is to discuss penetrating head injuries (PHIs) which, although rare, lead to considerable morbidity and mortality. One of the most significant culprits of PHI is the nail gun, which was introduced in 1959 and has gained substantial popularity. We describe our successful strategy for removing an 8-cm nail that penetrated through the orbit and middle cranial fossa, with the tip lodged within the posterior fossa. Vascular imaging and balloon test occlusion are imperative in circumstances where vessel sacrifice is necessary. In addition, positioning of balloons within large vessels that are in close proximity to the penetrating object is necessary to control bleeding that may occur during removal of the object. It is of paramount importance to have a multidisciplinary team participating in the management and eventual removal of foreign objects within the intracranial compartment. Included is a review of the literature and a discussion on management approaches to such injuries.

An unusual case of pneumatic nail gun scrotal injury and revision of the literature.

Pneumatic nail guns are hand-held tools commonly utilized in both industrial and non occupational setting. These devices facilitate production and boost efficiency but also can be a potential cause of serious injuries. Nail guns are the most frequent tool associated trauma with hospitalization among construction workers. The most common sites of injuries are the hand or fingers followed by the lower extremities. We report the first case in literature of a work nail gun injury to male external genitalia.

Serious injury and fatality investigations involving pneumatic nail guns, 1985-2012.

BACKGROUND: This article examines serious and fatal pneumatic nail gun (PNG) injury investigations for workplace, tool design, and human factors relevant to causation and resulting OS&H authorities' responses in terms of citations and penalties. METHODS: The U.S. Occupational Safety and Health Administration (OSHA) database of Fatality and Catastrophe Investigation Summaries (F&CIS) were reviewed (1985-2012) to identify n = 258 PNG accidents. RESULTS: 79.8% of investigations, and 100% of fatalities, occurred in the construction industry. Between 53-71% of injuries appear to have been preventable had a safer sequential trigger tool been used. Citations and monetary penalties were related to injury severity, body part injured, disabling of safety devices, and insufficient personal protective equipment (PPE). CONCLUSIONS: Differences may exist between construction and other industries in investigators interpretations of PNG injury causation and resulting citations/penalties. Violations of PPE standards were penalized most severely, yet the preventive effect of PPE would likely have been less than that of a safer sequential trigger.

Nail gun injuries treated in U.S emergency departments, 2006-2011: not just a worker safety issue.

BACKGROUND: Nail guns increase productivity in residential building but with a corresponding increase in worker injuries. They are also easily accessible, at low cost, to consumers. METHODS: Data from the occupational supplement to the National Electronic Injury Surveillance System (NEISS-Work) were used to calculate national estimates of work-related injuries from nail guns between 2006 and 2011. These were compared to estimates of consumer injuries obtained through online access to the Consumer Product Safety Commission's (CPSC) NEISS data. RESULTS: Approximately 25,000 ED-treated work-related and consumer nail gun injuries were estimated each year. During the construction economy collapse, injuries among workers declined markedly, closely following patterns of reduced residential employment. Reduction in consumer injuries was much more modest. CONCLUSIONS: Current nail gun injury patterns suggest marked blurring of work and home exposures. A united effort of CPSC, NIOSH, and OSHA is warranted to address these preventable injuries.

A Biomechanical Assessment of Hand/Arm Force with Pneumatic Nail Gun Actuation Systems.

A biomechanical model is presented, and combined with measurements of tip press force, to estimate total user hand force associated with two pneumatic nail gun trigger systems. The contact actuation trigger (CAT) can fire a nail when the user holds the trigger depressed first and then "bumps" the nail gun tip against the workpiece. With a full sequential actuation trigger (SAT) the user must press the tip against the workpiece prior to activating the trigger. The SAT is demonstrably safer in reducing traumatic injury risk, but increases the duration (and magnitude) of tip force exertion. Time integrated (cumulative) hand force was calculated for a single user from measurements of the tip contact force with the workpiece and transfer time between nails as inputs to a static model of the nail gun and workpiece in two nailing task orientations. The model shows the hand force dependence upon the orientation of the workpiece in addition to the trigger system. Based on standard time allowances from work measurement systems (i.e. Methods-Time Measurement - 1) it is proposed that efficient application of hand force with the SAT in maintaining tip contact can reduce force exertion attributable to the sequential actuation trigger to 2-8% (horizontal nailing) and 9-20% (vertical nailing) of the total hand/arm force. The present model is useful for considering differences in cumulative hand/arm force exposure between the SAT and CAT systems and may explain the appeal of the CAT trigger in reducing the user's perception of muscular effort.

A case of MRI-induced headache caused by an intracranial foreign body.

This case report delves into a unique occurrence of MRI-induced headaches attributed to an unsuspected intracranial foreign body. A male patient, presenting persistent headaches, experienced exacerbation of pain upon entering the MRI suite, hindering the imaging procedure. A subsequent head CT scan revealed a nail within the cranial cavity, stemming from a previous nail gun injury. Surgical removal was deemed unsafe, leading to continued observation. This case emphasizes the need for cautious exploration of abnormal symptoms in the MRI suite, urging healthcare professionals to consider potential foreign bodies. The incident underscores the risk of metallic fragments causing complications during MRI procedures and highlights the importance of thorough patient assessment before resorting to MRI imaging.

Nail gun injury to the median nerve: A barbed issue.

Nail gun injuries to the hand are an increasingly common encounter amongst those in the construction injury and a frequent presentation to the emergency department. Despite their frequency, nail gun injuries rarely involve significant structural injury. We present a rare case of severe injury by a barbed nail to the median nerve requiring surgical exploration. At our latest follow up 14 months post-operatively, the patient had ongoing sensory and motor deficits, cold intolerance and reduced proprioception and range of motion at the index finger. Continued hand therapy resulted in improved range of motion and desensitization. A systematic literature search has revealed no other reported cases of median nerve injury by nail gun.

Suicide by a construction nail fired from a pistol.

Penetrating head injury to accomplish suicide by a non-ammunition-related projectile discharged from a nail-gun is a very rare entity. The authors describe even much rarer, and the first reported case of a suicide penetrating head injury by a construction nail discharged from a blank cartridge of a pistol. The absence of beveling and muzzle impression, the non-ejection of the discharged cartridge, and the exit of just the tip of the nail from the other side of wound were the atypical features in this firearm fatality sustained at a contact-range. The entry wound prototypes like abrasion and grease collar, and blackening were absent. An improvisation to insert a construction nail into the chamber of firearm, for utilization as a projectile was another unique highlight here. The deceased was a construction builder. Being debt-ridden, he probably could not manage to purchase even one live cartridge for his licensee pistol to bring suicidal ideation to culmination.

A Nail in the Brain.

Transorbital penetrating brain injuries (TOPI) are rare. We report a case of industrial injury that resulted in perforating eye injury and intracranial foreign body by a nail gun. A 30-year-old man accidentally fired a nail gun onto his left eye at his construction workplace while handling the malfunctioned equipment and sustained a perforating injury of the left eye with intracranial foreign body. The misfired nail was lodged in his frontal lobe of the brain. He also suffered laceration wounds of the lateral canthus of the left eye and fractures of the left orbital floor and roof. He underwent emergency bicoronal craniotomy and removal of intracranial foreign body, followed by left eye examination under anaesthesia as well as scleral toilet and suturing. The nail was successfully removed. He recovered well with no neurological deficit and was discharged on postoperative day 5 with a Glasgow Coma Scale score of 15; however, his left eye vision remained no perception of light. Work-related eye injuries can be debilitating and are largely preventable.

Non-operative Management of an Accidental Knee Intra-articular Nail.

Nail gun injuries are relatively common presentations to the emergency department. The majority of these injuries occur to the hands and rarely result in long-term morbidity. However, despite the large number of cases each year, little research is available regarding the optimum emergency management of nails that implant intra-articularly. Initial studies suggested that cases of nails penetrating intra-articular or neurovascular structures warranted operative debridement; however, newer studies have suggested cautious nail removal, wound debridement, irrigation, antibiotic coverage, and tetanus prophylaxis are equivalent to operative intervention for the management of most intra-articular nails. We present a gentleman in his 40s with accidental penetration of a nail fired from a nail gun into his right knee. He was neurovascularly intact. After initial evaluation and management, he was transported to a higher level of care for operative management. However, the nail was ultimately removed bedside utilizing adequate anesthesia.

Ultrasound-guided interventional approach to intraperitoneal nail gun injury: A case report with literature review.

Literature review suggests that surgery is the only option for dealing with intraperitoneal foreign bodies (laparoscopy and laparotomy). We showed that an interventional method using ultrasound guidance could be considered alongside surgical options.

[Self-inflicted cardiac injury : He "nailed" it]. / Plaie cardiaque auto-infligée : il l'a « cloué ¼.

INTRODUCTION: Nail guns are responsible for an estimated 14% of injuries among residential carpenters, intrathoracic injuries are rare but almost always require operative management with a sternotomy or thoracotomy. CASE REPORT: We report the case of a young carpenter who injured himself by accident during work. The nail perforated the right ventricle. He was operated and postoperative course was uneventful. CONCLUSION: This case highlights the importance of urgent and adequate management of these cases and the need to raise awareness about work safety among carpenters.

Delayed-Onset Seizures Following Self-Inflicted Nail Gun Injury to the Head: A Case Report and Literature Review.

Nail gun use and its associated incidence of injury have continued to increase since it was first introduced in 1959. While most of these injuries involve the extremities, a subset of patients suffer intracranial trauma. The most recent comprehensive review on this particular subject referenced 41 cases and advocated for further discussion regarding proper treatment plans for these individuals. We present the case of a 25-year-old who suffered 35 self-inflicted penetrating head wounds from a nail gun after suffering an amputation injury at his job site. No neurological deficits were present on his arrival to the emergency room. He underwent surgery to treat his arm wound and remove 13 of the 35 nails. The patient was discharged from the hospital on levetiracetam and made a full recovery. Nearly 1 year later, he experienced a seizure at his workplace. However, after resuming his antiepileptic medication, he reports no further complications. This case is distinct for not only being the most nails in a patient's head at presentation, but also following surgery. Utilizing this case, prior review, and 27 subsequent cases, we propose an updated algorithm for diagnosis and treatment of nail-gun-related penetrating head trauma.