Elevated blood lead resulting from maxillofacial gunshot injuries with lead ingestion

The Use of MartriDerm in Nail Bed Reconstruction of Thumb Injured by a Pellet

Gunshot injuries to the hand and upper extremity can be divided into low and high-energy injuries. Nonballistic firearms such as pellet guns are generally considered low-energy guns but can be associated with serious morbidity and even mortality. Management is tailored according to the severity and type of injured structures. Here, we present the case of a 21-year-old soldier who accidently shot his thumb with an air gun while on a bird hunting trip, whose case was managed with extraction placement of bone graft and collagen matrix to prevent nail deformity. This case was written to increase the awareness about the need for safe use of such guns and to display the authors preferred way of management.

Retained bullets and lead toxicity: a systematic review

INTRODUCTION

Lead toxicity secondary to retained bullet(s) (RB) after a penetrating gunshot wound is a rare but likely underdiagnosed condition, given the substantial number of firearm injuries in the United States. There is currently no consensus on the indications for surveillance, chelation, or surgical intervention.

OBJECTIVE

The purpose of our review is to summarize the literature on systemic lead toxicity secondary to RBs to help guide clinicians in the management of these patients.

METHODOLOGY

The primary literature search was conducted in Medline (PubMed), EMBASE, Cochrane, and CENTRAL using the following MESH terms: "chelation" and "lead poisoning" or "lead toxicity" or "lead" and "bullet" or "missile" or "gunshot", or "bullet".

RESULTS

The search identified 1,082 articles. After exclusions, a total of 142 articles were included in our final review, the majority of which were case reports. Several factors appear to increase the risk of developing lead toxicity including the location of the RB, the presence of a fracture or recent trauma, number of fragments, hypermetabolic states, and bullet retention duration. Particularly, RBs located within a body fluid compartment like an intra-articular space appear to be at a substantially higher risk of developing lead toxicity. Even though patients with lead toxicity from RBs will have similar symptoms to patients with lead toxicity from other sources, the diagnosis of lead poisoning may occur months or years after a gunshot wound. Symptomatic patients with high blood lead levels (BLLs) tended to improve with a combination of chelation and surgical removal of RBs.

CONCLUSIONS

We suggest surveillance with serial BLLs should be performed. Patients with intra-articular RBs appear to be at increased risk of lead toxicity and if possible, early surgical removal of the RBs is warranted, especially given that signs of toxicity are vague, and patients may not have access to follow-up. Long-term chelation should not be used as a surgical alternative and management should be multidisciplinary.

Air gun wound: bihemispheric penetrating brain injury in a paediatric patient

Air guns are classified as low-velocity missiles and they usually considered safe and harmless. Despite that fact, air guns still can make serious or life-threatening injuries. Most of air gun injuries occur in paediatric population. A 2-year-old boy was shot in the forehead withan air gun accidentally. Skull radiography and non-contrast CT scan of the head were performed and showed penetrating bihemispheric brain injury from the left frontal to right occipital lobes at the level of the lateral ventricle with a metal-density foreign body at the right occipital. A projectile was successfully extracted via craniotomy, without complications. Air guns have the potential to cause fatal, life-threatening injury especially in children. Imaging is crucial for the evaluation of wound ballistics. Understanding about the mechanism of projectiles and wound ballistics is very helpful for radiologists to conceptualize these injuries when interpreting these cases. The role of radiology in ballistic wound cases is critical and important, both for clinical and forensic settings.

Nausea, Vomiting, and Weight Loss in a Young Adult Patient With a History of a Gunshot Wound

Assessing victims of gunshot wounds with retained bullets/bullet fragments for lead toxicity is not always considered until the patient develops signs and symptoms of toxicity. We discuss the case of a 19-year-old young man who received a diagnosis of chronic lead toxicity (serum lead concentration 51 μg/dL) 5 weeks after a hunting accident. Extensive wound debridement occurred following the accident; however, lead toxicity was not diagnosed until after his fourth emergency department visit. Oral chelation therapy was required for the management of his lead toxicity.

Removal of infratemporal fossa foreign body under C-arm

A 12-year-old boy presented to our emergency department after being shot in the face. A computed tomographic scan revealed a bullet through the posterolateral wall of the maxillary sinus into the right infratemporal area, just adjacent to the skull base. We elected transantral approach with the help of endoscopy and C-arm. The bullet was successfully removed. Little is known on the best strategy for removing the infratemporal foreign body. Our experience in this case provides a safe and effective way for such injury.

[Gunshot wounds: should projectiles and fragments always be removed?]

BACKGROUND

Projectiles or metal fragments can remain lodged in the body of victims of gunshot injuries. This also applies to projectiles which do not tend to deform or fragment on impact. When a projectile fragments on penetration, jacket or lead core particles are likely to remain lodged in the affected region even if the projectile has exited the body.

AIM OF THE STUDY

A frequently asked question in the surgical management of such injuries is whether there are medical indications for the surgical removal of projectiles or fragments.

MATERIAL AND METHODS

This article presents some typical cases of patients who have received treatment at our institution and reviews the pertinent literature to show general recommendations in special cases concerning the removal of projectiles or fragments and when additional surgical trauma is justified. Parameters for decision making are presented in an algorithm.

RESULTS

From our own patients, 5 with remaining fragments in the soft tissue were invited for a clinical follow up. Serum probes and 24 h urine output was analysed for serum lead levels and urinary aminolevulinic acid levels. 74 months (max. 128 - min. 42 months) after injury we documented not elevated serum lead levels of 8.25 μg/ml and urinary aminolevulinic acid levels of 4.8 mg/24 h.

DISCUSSION

When lead-containing projectiles or fragments remain lodged in the body, monitoring is required and includes the measurement of serum lead levels and urinary aminolevulinic acid levels. The most important clinical symptoms of lead poisoning are gastrointestinal and neurological in nature. The treatment of choice for lead poisoning is the administration of chelating agents and removal of the lead source by surgical intervention.

Air gun pellet remaining in the maxillary sinus for 50 years: a relevant risk factor for the patient?

The authors report the case of a 62-year-old man referred to the department of oral and maxillofacial surgery because of a clinical suspicion of palate carcinoma. Incidentally, diagnostic radiology showed a metallic foreign body in the left maxillary sinus. Anamnestic data revealed that a shot from an air gun accidentally hit the patient's left cheek in 1957. The lead-containing air gun pellet was removed by endoscopic antrostomy and the diagnosis of squamous cell carcinoma was confirmed by histopathological examination. 50 years after the pellet's impact, toxicological blood analysis showed no increased blood lead level. It remains unclear whether the air gun pellet has a potential toxicological effect or is related to the development of the patient's oral carcinoma. In this context the article reviews the literature and discusses the necessity of removing metal-containing foreign bodies, the role of lead in chronic toxicity and its possible carcinogenic effect in humans.

Determining tissue-lead levels in large game mammals harvested with lead bullets: human health concerns

Recently, the use of lead isotope ratios has definitively identified lead ammunition as a source of lead exposure for First Nations people, but the isotope ratios for lead pellets and bullets were indistinguishable. Thus, lead-contaminated meat from game harvested with lead bullets may also be contributing to the lead body burden; however, few studies have determined if lead bullet fragments are present in big game carcasses. We found elevated tissue-lead concentrations (up to 5,726.0 microg/g ww) in liver (5/9) and muscle (6/7) samples of big game harvested with lead bullets and radiographic evidence of lead fragments. Thus, we would advise that the tissue surrounding the wound channel be removed and discarded, as this tissue may be contaminated by lead bullet fragments.

Conventional radiographs: are they still the standard in localization of projectiles?

The penetration of air gun pellets in facial soft tissue can cause major problems during the removal of foreign bodies, although conventional radiography, computed tomography, image-guided surgical removal, and ultrasound have been applied to facilitate the procedure. It was the aim of the present case report to introduce a modified intraoperative method for the localization of air gun pellets, based on the use of radiopaque markers in conventional radiographs. A 66-year-old patient attempted to commit suicide by using an air gun. The pellet hit the right temporal region. A computed tomographic (CT) scan was acquired to localize the foreign body. The first attempt to remove the pellet through the penetrating wound failed. Because of a dislodgement of the pellet, the CT scan could no longer be used for the localization of the air gun pellet. As the air gun pellet was positioned under the zygomatic arch, ultrasound was unable to identify its position. Successful intraoperative localization of the projectile was performed after fixation of radiopaque markers to the skin in the region of the estimated localization, with conventional radiographs in 2 planes, acquired with a mobile dental x-ray device. Although the markers remained attached to the patient as reference makers, the air gun pellet was removed easily. The use of radiopaque markers in conventional radiographs in 2 planes allows fast, intraoperative localization of radiopaque foreign bodies within soft tissue. The procedure can be carried out with a conventional x-ray device that should be available in every oral and maxillofacial practice. The use of reference markers should be considered a standard procedure for the localization of radiopaque foreign bodies in the head and neck.

Evaluation of potentially significant increase of lead in the blood during long-term bed rest and space flight

We address a gap in the knowledge of lead turnover under conditions of prolonged bed rest and microgravity by developing a quantitative model of the amount of lead returned to blood circulation from bone. We offer the hypothesis that skeletal unloading, such as typically occurs during extended bed rest or microgravity, will result in bone lead being released to the blood, as has already been demonstrated in the case of calcium. We use initial bone lead concentrations to develop predictive models of blood lead elevation. Our theoretical calculations with typical bone lead loads measured in today's 40-60-year-old generation, suggest that the estimated blood lead concentrations in long duration (e.g., 100 days) space flight could average between 20 and 40 microg dl(-1), a range with well-established toxic effects. For a similar duration of bed rest, estimated blood lead concentration could be as high as 10-20 microg dl(-1), which is a level of concern, particularly if we consider females of childbearing age. The preliminary experimental results were obtained under multi-institutional collaborations, with the main outcome received from an on-going bed rest study, Prevention of Microgravity-Induced Stone Risk by KMgCitrate, conducted at the General Clinical Research Center (GCRC) of the University of Texas Southwestern Medical Center, Dallas. Based on theoretical modeling and some preliminary experimental results, this concept may have important clinical implications by allowing prediction of the magnitude of blood lead elevation, thereby establishing the means to prevent lead toxicity during long duration space flight of astronauts and in conditions of prolonged bed rest such as complicated pregnancy, spinal cord injury induced paralysis and comatose patients.