accidents with a pneumatic nail gun , which has been used in the construction industry , have increased.2 ) however , reports on management of a patient with a nail gun injury to the cranium are rare
. the authors report on a case of a patient treated with simple retraction after small skin and prophylactic antibiotic administration .
a 56-year - old man had five nail gun - shots due to attempted suicide and was transferred to the emergency room . on his physical examination ,
his mental status was drowsy and there was no neurological deficit except for nails on his cranium . in his past history , there was no psychological background , however , he used to drink often and became depressed . on plain skull radiography ,
five nails were found ( figure 1a ) . among the five nails , two penetrated glabella .
two nails were located in the right parietal bone and another was located in the left parietal bone . due to the head of the nail , the direction was confined to the outer table of the skull .
in addition , a subarachnoid hemorrhage was observed on brain computed tomography ( ct)(figure 1b ) .
all procedures were performed in the operating room under general anesthesia in order to treat the emergent condition as rapidly as possible .
the nail head was located beneath the scalp and tightly attached to the skull , it was not visible from the outside . a small incision to advance a forceps and a rongeur was necessary , and
, all nails were removed successfully ( figure 1c ) . during the period of conservative management
antibiotics including vancomycin , ceftriaxone , and metronidazole were administered for two weeks and carbamazepine was administered for a week .
conventional angiography was performed , and there was no vascular invasion or newly formed fistula ( figure 1d ) .
head injury by pneumatic nail gun injury is rare , and there have been some case reports on management , treatment . according to lee and park,4 ) the speed of the launched nail and presence of the nail head are important determinants of the extent of nail gun related head injuries
. if major artery or sinuses are not involved , extraction from the nail head could be the main treatment .
ct is typically the first - line radiologic examination in the emergency room for head - injured patients . in general , ct shows excellent details in bone and average value in soft tissue . failure to recognize cerebral damage following penetrating brain injuries ,
especially when there is retained foreign body , can lead to serious life - threatening complications.1 ) in addition , because involvement of the large vessels is critical to determining the operative strategy , vascular integrity should be evaluated with ct angiography or ct enhanced image in the initial evaluation in the emergency room . in this case , nails were removed by a small scalp incision due to the fact that major artery or sinuses were not involved . if this is not the case , management would be direct ligation or vascular bypass surgery . despite many controversies regarding use of prophylactic antibiotics , the authors believe that broad spectrum antibiotics are appropriate for patients with penetrating brain injury since
it is also recommended that antibiotics should be started as soon as possible.3 ) post - traumatic epilepsy is a major cause of disability and inadequate social integration .
although there is no prospective study to indicate the efficacy of prophylactic anti - epileptic medication following a traumatic brain injury , it has been recommended that patients be covered for about the first week after injury with a medication such as phenytoin or carbamazepine.5 )
in the patient with head injury by pneumatic nail gun , the first evaluation should focus on the shape of the nail head and vascular integrity from simple x - ray and ct .
if the nail head is confined to the depth of skull penetration , cautious extraction of the nail head can be performed without postoperative complication and early start of prophylactic antibiotics can be the next treatment .
 a 56-year - old man had five nail gun - shots on his skull due to attempted suicide and was transferred to the emergency room . because the nail head played a role as a brake , the launched nail made a hole in the skull but did not entirely pass through it . 
 if major artery or sinuses are not involved , cautious retrieval after a small scalp incision can be performed and prophylactic antibiotics be administered for treatment . 
Introduction
Case Report
Discussion
Conclusion