Nail gun injuries often occur in the extremities, but im­portant organs such as the heart and brain can be damaged in some cases. Some of them result in several wounds and require urgent surgical interventions. Because injuries of multiple organs are extremely rare, the priority of surgical treatments is not established and should be considered according to each case. Herein, we report a case of penetrating heart and head injuries caused by a nail gun. A 44–year–old man was admitted to our institute after shooting himself using a nail gun the previous day. His conscious­ness was clear without the neurological deficit and his vital signs were stable despite the vital organ injuries. Chest Computed Tomography (CT) scan showed a nail penetrated his heart and head CT revealed the tips of 2 nails reached the right frontal lobe and the right temporal lobe respectively, but they did not indicate cardiac tamponade and intracranial hemorrhage. The other 4 nails around the oc­cipital and cervical portion did not reach the intracranial and stopped in the subcutaneous tissue. After consultation with cardiovascular surgeons, we decided to perform sur­gery on his heart first, because the nail can get deeper and destroy his heart owing to its beat. It was performed using a cardio–pulmonary bypass under heparin administration. After measuring activated clotting time, we confirmed that the effect of heparin had disappeared, and started cranio­tomy. All the nails were successfully removed. The postoperative course was uneventful without neurological defi­cit and complications, and he was discharged on the 16th postoperative day. In the case of multiple organ injuries, rational strategy and earlier surgical interventions are in­dispensable for a good prognosis.

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〔要旨〕症例は84歳，男性。自動釘打機での自傷行為で，頭部，前胸部に釘を打ち込み受傷した。CTで頭部と前胸部に釘の残存と，心損傷，肺損傷，脳損傷を認めたため，緊急で開胸止血術と開頭異物除去術を施行した。胸部の術中所見として，心膜に明らかな鋭的損傷を認めず，心尖部近くの心筋にoozingを伴う暗赤色変化を認めるのみだったことから，自動釘打機の衝撃による鈍的心損傷と診断した。自動釘打機による四肢以外の臓器損傷はまれであり，無症状から血行動態の破綻までさまざまな経過を呈する。胸部に創部がある場合，鋭的損傷だけでなく鈍的損傷でも全身状態が増悪する可能性があるため，迅速な評価，治療介入が救命に重要と考えられる。

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Published reports on nail-gun injuries to the head are rare. We describe the case of a penetrating cranio-submental injury with internal carotid arterial stenosis. A 30-year-old man sustained a penetrating head injury inflicted by a nail gun. On admission, he was conscious and had no neurological deficits. X-ray films of the skull showed that the nail had penetrated deeply into the left lacerated foramen from the submental space. CT scans showed no evidence of intracranial hemorrhage, but angiography suggested constriction of the left internal carotid artery by the nail. On the night of admission day 1, the patient had right hemiparesis with a disturbance of consciousness caused by the constriction. On 2nd day after the penetrating injury, his condition improved considerably by intravenous administration of heparin and edaravone.
On the same day, the nail was easily and safely removed from the oral floor after coil embolization of the left internal carotid artery. On the 18th day, the patient was discharged with slight aphasia.

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　穿通性頭部外傷は箸，傘，ペンなどの日常生活用品の他に，刃物，ガラス片，

などの鋭利なものによっても生じる．我々は，エンジン式草刈り機の刃という比較的稀な原因による経眼窩的穿通外傷を経験したので報告する．症例は69歳男性で，草刈り機で作業中に右眼に異物が当たり，近医眼科で眼球破裂ありとのことで，walk‒inで当院救急外来を受診した．意識はJCS 2，GCS 14（E4V4M6），右視力は光覚弁であった．運動麻痺はなかった．頭部XPで右眼窩内，右頰部，右前頭葉内に複数の金属製異物を認めた．頭部CTでは左側に無症候性の慢性硬膜下血腫と右前頭葉内に３つの異物が確認できた．まず眼窩内の金属片を除去し，その後開頭によって頭蓋内異物を摘出した．異物は島回の前方にあると考えられたため，シルビウス裂を開放して経皮質的に摘出した．頭蓋内異物は骨片と欠けた草刈り機の刃であった．眼窩内異物の位置同定にはX線透視が，頭蓋内異物の位置同定にはエコーが有用であった．術後の意識はJCS 2，高次脳機能障害を認めたが徐々に快復し，mRS 2で退院した．穿通性頭部外傷は日常診療で遭遇することは稀であるが，搬入されてきた際に慌てず速やかに治療を行う体制と心構えが必要である．

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パーティクルボード（PB）張り水平構面の床倍率に関するデータ整備を目的に，根太間隔の異なる2種類の床構面および釘接合条件の異なる2種類の桁上水平構面のせん断試験を行った。床構面（JIS 18Mタイプ15mm厚PB，N50釘，150mm間隔，川の字打ち）では，根太間隔455 mmから303mmへの変更（釘本数は約1.4倍）により，降伏耐力は27％増，終局耐力は35％増となり，結果として床倍率（低減係数1.0）は2.3から2.9へと増加した。桁上水平構面（JIS 18Mタイプ12mm厚PB，四周釘打ち，150mm間隔）では，釘の種類と縁端距離をN50，12mmからCN50，25mmに変更することで，降伏耐力は14％増，終局耐力は26％増となり，結果として床倍率（低減係数1.0）は2.8から3.6へと増加した。

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症例は42歳の女性。統合失調症で他院通院加療中に突然の希死念慮のため文化包丁で自分の腹部を刺し受傷1時間45分後に救急搬送された。来院時包丁は腹部に刺さったまま固定された状態であった。造影CT検査で膵頭部，胃前庭部～十二指腸の損傷を疑い受傷4時間15分後に緊急開腹術を施行した。包丁先端は十二指腸球部を穿通し膵頭部上縁実質を約5mm幅で穿通し椎体腹側に達していた。助手が包丁を固定した状態で慎重に損傷部位の検索を行い主膵管・胆管・主要血管の損傷がないと判断した時点で包丁を抜去し，穿孔部を含む胃十二指腸切除＋膵頭部縫合閉鎖を行った。術後経過は良好で術後17日目にかかりつけ精神科に転院となった。本邦の腹部外傷は鈍的外傷が多く刺創に遭遇する機会は少ない。自験例では成傷器が残存した状態にあり詳細な術前評価は困難であったが，注意深い手術操作のもと検索を行うことで良好な経過を得ることができた。

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The outcome of penetrating head trauma is relatively poor, because some nerves, vascular structures and eloquent brain areas are directly injured and infection rate is very high. There are various penetrating substances, which must be dealt with flexibly. In penetrating head trauma, penetration of the calvaria is rare, because of the existence of hard skull bone. We report a case of transcranial head trauma caused by a nail–gun.

A 53–year–old man attempted suicide using a nail–gun, shooting nails into the temporal and frontal lobes. On admission examina­tion, the patient was found to have impaired consciousness with Japan Coma Scale (JCS) 3 and incomplete right hemiparesis. Computed tomography showed nails in the right frontal, left frontal, and left temporal lobes. The nail in the left temporal lobe penetrated from the forehead to the temporal lobe of the left basal ganglia and was accompanied by intracerebral hemorrhage along the passway. Cerebral angiography confirmed that these nails did not injure any artery nor vein. The right temporal nail was manually removed under local anesthesia. The next day, the nails in the left frontal and left temporal lobes were removed by craniotomy, and the damaged frontal sinus was repaired using a pericranial flap. The left temporal nail had a deep head and was pulled out retrogradely from the tip. We could be safely removed by peeling off the surrounding brain matter. Postoperative bleeding and cerebro­spinal fluid leakage did not occur. Administration of antibacterial agents was started earlier from admission, and a follow–up cranial Magnetic Resonance Imaging confirmed no complications such as abscess formation. In this case, the three nails were surgically re­moved within 48 hours. For penetrating head injuries, removing the foreign body as soon as possible is recommended to avoid infec­tion, but there are no established removal methods. A tailored operation for each case is required considering the foreign body’s position, penetration route, and the damaged part’s location. Although careful follow–up will be required, we examined the acute treatment strat­egy for penetrating head trauma, including a review of literature.

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