Teaching image withheldThe image will be revealed when it becomes clinically available in the case.
OPERATIVE image: open thoracic exposure showing a retained nail embedded in the heart, with surrounding myocardial injury and surgical instruments exposing the field. The confirmed finding is a nail penetrating the heart; the nail remains in situ during thoracotomy. • TEACHING IMAGE
Intraoperative Management of a Retained Nail Penetrating the Heart
SCENARIO
A worker is struck in the precordium by a nail fired from a pneumatic nail gun. The nail remains embedded and is not manipulated in the field. On arrival, he is conscious but anxious, with tachycardia, hypotension, muffled heart sounds, and a left parasternal wound. He has a weak but present pulse and transient improvement after blood products. A focused cardiac ultrasound shows pericardial fluid and a linear echogenic foreign body traversing the cardiac silhouette. Because of ongoing concern for cardiac penetration and marginal but temporarily supported hemodynamics, the trauma team proceeds urgently to the operating room with the nail stabilized in place. After thoracotomy and exposure of the heart, the operative image becomes available.