Int J Emerg Med (2010) 3:135–137 DOI 10.1007/s12245-009-0152-5 CASE REPORT Nail gun penetrating injury of the heart mimicking an acute coronary syndrome Chiara Comoglio & Fabrizio Sansone & Massimo Boffini & Marco Ribezzo & Mauro Rinaldi Received: 7 June 2009 / Accepted: 29 November 2009 / Published online: 5 February 2010 # Springer-Verlag London Ltd 2010 Abstract We describe the case of a 75-year-old man admitted to hospital for chest pain and syncope. Physical examination was normal with evidence of a very small wound on the left chest. Considering the presence of multiple coronary risk factors, an acute coronary syndrome was initially suspected, but the electrocardiogram (EKG) was normal and only a slight increase of cardiac enzymes was detected. The hypothesis of aortic dissection was also considered and in order to discriminate between the aortic and coronary syndrome, a thoracic and coronary computed tomography (CT) scan was performed. The CT scan showed a metallic structure, suggestive of a nail, about 6 cm in length, in the deep layers of the left ventricular wall and a small pneumothorax due to a lung lesion. The patient was therefore transferred to our department for urgent cardiac surgery that was performed without complications. Keywords Chest trauma . Nail gun penetrating injury . Trauma management . Acute coronary syndrome . Aortic dissection Introduction Accidents with nail guns usually cause orthopaedic lesions of the non-dominant arm, but just a few cases of cardiac C. Comoglio : F. Sansone (*) : M. Boffini : M. Ribezzo : M. Rinaldi Division of Cardiac Surgery, University of Turin, San Giovanni Battista Hospital, C.so Bramante 88, 10127 Turin, Italy e-mail: fabrisans@katamail.com injuries have been reported. The incidence of self-inflicted cases is actually rising and some cases have been reported. The right ventricle is most frequently involved because of its anterior location [1], but the aorta and other mediastinal structures may be damaged. Although these injuries are now considered survivable, the mortality rate of nail gun injuries reported in the literature is about 25% [2]. Clinical summary We describe the case of a 75-year-old man with multiple cardiac risk factors like hypertension, diabetes mellitus, and smoking who experienced an episode of chest pain and syncope while he was working on some domestic jobs. He was hospitalized for suspected acute coronary syndrome (ACS). Physical examination was normal except for the presence of a small wound on the left chest wall whose origin the patient could not explain. The electrocardiogram (EKG) was normal, and cardiac enzymes were slightly increased (troponin T 0.12 ng/ml). To discriminate between ACS and aortic syndrome, thoracic and coronary computed tomography (CT) scanning was performed. CT scanning revealed a nail of about 6 cm in length in the deep layers of the left ventricular wall and severe calcification of the left anterior descending artery (LAD) without coronary lesions due to the nail (Fig. 1a, b). Echocardiography showed mild pericardial effusion without signs of cardiac tamponade, normal ejection fraction (EF), and the presence of a foreign body in the deep layers of the lateral wall. The patient was transferred to our department for urgent cardiac surgery. He was stable and in order to clarify the LAD calcifications, coronary angiography was performed (Fig. 1b). It showed normal coronary arteries and confirmed the presence of a nail in the lateral wall. The patient underwent surgery: we