A life-and-death race against time triggered by a nail

A 54-year-old male was brought to the emergency room by several co-workers after accidentally being shot in the chest with a nail gun. Laboratory tests revealed an elevated white blood cell count (18.10 × 10⁹/L; normal <10 × 10⁹/L), an increased percentage of neutrophils (89.9%; normal 40–75%), elevated high-sensitivity troponin I (1362.5 pg/mL; normal 0–26.2 pg/mL), and elevated D-dimer levels (2104 ng/mL; normal 0–500 ng/mL). The Point-of-Care Cardiac ultrasound revealed that the nail was lodged intact in the right atrium (Panel A). Computed tomography scan showed a foreign object in the right atrium with metal artefacts, consistent with the findings of the bedside cardiac ultrasound (Panel B). During the surgery, transoesophageal echocardiography confirmed that the nail was located in the right atrium, accompanied by papillary muscle rupture and severe tricuspid valve regurgitation (Panel C; Supplementary data online, Videos S1 and S2). The surgical team observed a 3 cm open wound near the xiphoid process in the lower chest wall, a perforation in the pericardium, and a large amount of thrombus in the pericardial cavity. A 2 cm penetrating wound was also found in the anterior wall of the right ventricle, covered by a blood clot. The papillary muscle connected to the posterior leaflet of the tricuspid valve was ruptured, and a water injection test revealed significant tricuspid valve regurgitation. The nail was found inserted into the roof of the right atrium near the aortic sinus wall, penetrating about 1 cm deep, with no haematoma or aortic valve regurgitation observed in the aortic root (Panel D).

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Supplementary data are available at European Heart Journal - Cardiovascular Imaging online.

Funding

Hubei Provincial Natural Science Foundation Joint Fund Project (JCZRLH202500705).

Data availability

The data underlying this article are available in the article and in its online Supplementary material.

Author notes