The Effects of Retained Lead Bullets on Body Lead Burden

Inflammatory low back pain with radiculopathy revealing epidural disintegration of a bullet complicated by lead poisoning

Inflammatory low back pain with radiculopathy is suggestive of cancer, infection or inflammatory diseases. We report a unique case of a 42-year-old patient with an acute inflammatory low back pain with bilateral radiculopathy associated with weight loss and abdominal pain, revealing the disintegration of a lead bullet along the epidural space and the S1 nerve root complicated by lead poisoning. Because of the high blood lead level of intoxication (>10 times over the usual lead levels) and the failure of repeated lead chelator cycles, a surgical treatment to remove bullet fragments was performed. It resulted in a significant decrease of pain and lead intoxication.

Succimer chelation does not produce lasting reductions of blood lead levels in a rodent model of retained lead fragments

Retained lead fragments from nonfatal firearm injuries pose a risk of lead poisoning. While chelation is well-established as a lead poisoning treatment, it remains unclear whether chelation mobilizes lead from embedded lead fragments. Here, we tested whether 1) DMSA/succimer or CaNa2EDTA increases mobilization of lead from fragments in vitro, and 2) succimer is efficacious in chelating fragment lead in vivo, using stable lead isotope tracer methods in a rodent model of embedded fragments. DMSA was > 10-times more effective than CaNa2EDTA in mobilizing fragment lead in vitro. In the rodent model, succimer chelation on day 1 produced the greatest blood lead reductions, and fragment lead was not mobilized into blood. However, with continued chelation and over 3-weeks post-chelation, blood lead levels rebounded with mobilization of lead from the fragments. These findings suggest prolonged chelation will increase fragment lead mobilization post-chelation, supporting the need for long-term surveillance in patients with retained fragments.

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.

Gunshot Wounds: Ballistics, Pathology, and Treatment Recommendations, with a Focus on Retained Bullets

As the epidemic of gunshot injuries and firearm fatalities continues to proliferate in the United States, knowledge regarding gunshot wound (GSW) injury and management is increasingly relevant to health-care providers. Unfortunately, existing guidelines are largely outdated, written in a time that high-velocity weapons and deforming bullets were chiefly restricted to military use. Advances in firearm technology and increased accessibility of military grade firearms to civilians has exacerbated the nature of domestic GSW injury and complicated clinical decision-making, as these weapons are associated with increased tissue damage and often result in retained bullets. Currently, there is a lack of literature addressing recent advances in the field of projectile-related trauma, specifically injuries with retained bullets. This review aims to aggregate the available yet dispersed findings regarding ballistics, GSW etiology, and treatment, particularly for cases involving retained projectiles.

Retained Bullets After Firearm Injury: A Survey on Surgeon Practice Patterns

Retained bullets are common after firearm injuries, yet their management remains poorly defined. Surgeon members of the Eastern Association for the Surgery of Trauma (N = 427) were surveyed using an anonymous, web-based questionnaire during Spring 2016. Indications for bullet removal and practice patterns surrounding this theme were queried. Also, habits around screening and diagnosing psychological illness in victims of firearm injury were asked. Most respondents were male (76.5%, n = 327) and practiced at urban (84.3%, n = 360), academic (88.3%, n = 377), Level 1 trauma centers (72.8%, n = 311). Only 14.5% (n = 62) of surgeons had institutional policies for bullet removal and 5.6% (n = 24) were likely to remove bullets. Half of the surgeons (52.0%, n = 222) preferred to remove bullets after the index hospitalization and pain (88.1%, n = 376) and a palpable bullet (71.2%, n = 304) were the most frequent indications for removal. Having the opportunity to follow-up with patients to discuss bullet removal was significantly predictive of removal (odds ratio (OR) = 2.25, 95% confidence interval (CI) = [1.05, 4.85], p = .04). Furthermore, routinely asking about retained bullets during outpatient follow-up was predictive of new psychological illness screening (OR = 1.94, 95% CI [1.19, 3.16], p = .01) and diagnosis (OR = 1.86, 95% CI = [1.12, 3.09], p = .02) in victims of firearm injury. Thus, surgeons should be encouraged to allot time for patients concerning retained bullet management so that a shared decision can be reached.

A Potentially Dangerous Industrial Projectile Lodged in the Leg of a Steel Factory Worker

Penetrating injuries due to fragments energized by an explosive event are life/limb-threatening and are associated with poor clinical and functional outcomes. Penetrating injuries are commonly inflicted in attacks with explosive devices. The extremities, especially the leg, are the most commonly affected body areas, presenting a high risk of infection, slow recovery, and the threat of amputation. This report presents a case of a young factory worker who sustained an injury to the leg with a foreign body lodged near the neuro-vascular bundle.

A 44-year-old gentleman sustained a projectile injury while working in a stainless steel factory from the rula (steel rolling) machine with a foreign body getting lodged in the leg in March 2019. He was initially managed with wound care and didn't report any functional impairment. Gradually patient developed numbness and claudication symptoms of the foot over the next couple of years. He was subsequently operated on in 2021 for removal of the stainless steel foreign body encased in dystrophic calcification close to the tibial nerve and posterior tibial vessels. Interestingly the entry point of the foreign body was on the anterolateral aspect of the leg. The foreign body was removed using the postero-lateral approach to the tibia with careful dissection close to the neurovascular bundle. At a follow-up of 3 months, the patient is symptom-free with significant improvement of limb function.

The authors propose that the foreign body crossed the interosseous membrane to get lodged close to the posterior tibial neurovascular bundle. In such a scenario, the patient was extremely lucky to have survived an amputation or significant functional injury of the limb. Proper protective equipment is needed not only for the torso but also for extremities to protect industrial workers from such limb-threatening injuries. Moreover, primary care physicians should be sensitised for the proper management of such injuries.

Environmental and health hazards of military metal pollution

An increasing body of literature has demonstrated that armed conflicts and military activity may contribute to environmental pollution with metals, although the existing data are inconsistent. Therefore, in this paper, we discuss potential sources of military-related metal emissions, environmental metal contamination, as well as routes of metal exposure and their health hazards in relation to military activities. Emission of metals into the environment upon military activity occurs from weapon residues containing high levels of particles containing lead (Pb; leaded ammunition), copper (Cu; unleaded), and depleted uranium (DU). As a consequence, military activity results in soil contamination with Pb and Cu, as well as other metals including Cd, Sb, Cr, Ni, Zn, with subsequent metal translocation to water, thus increasing the risk of human exposure. Biomonitoring studies have demonstrated increased accumulation of metals in plants, invertebrates, and vertebrate species (fish, birds, mammals). Correspondingly, military activity is associated with human metal exposure that results from inhalation or ingestion of released particles, as well as injuries with subsequent metal release from embedded fragments. It is also notable that local metal accumulation following military injury may occur even without detectable fragments. Nonetheless, data on health effects of military-related metal exposures have yet to be systematized. The existing data demonstrate adverse neurological, cardiovascular, and reproductive outcomes in exposed military personnel. Moreover, military-related metal exposures also result in adverse neurodevelopmental outcome in children living within adulterated territories. Experimental in vivo and in vitro studies also demonstrated toxic effects of specific metals as well as widely used metal alloys, although laboratory data report much wider spectrum of adverse effects as compared to epidemiological studies. Therefore, further epidemiological, biomonitoring and laboratory studies are required to better characterize military-related metal exposures and their underlying mechanisms of their adverse toxic effects.

Retained bullet fragments after nonfatal gunshot wounds: epidemiology and outcomes

BACKGROUND

With no consensus on the optimal management strategy for asymptomatic retained bullet fragments (RBF), the emerging data on RBF lead toxicity have become an increasingly important issue. There are, however, a paucity of data on the magnitude of this problem. The aim of this study was to address this by characterizing the incidence and distribution of RBF.

METHODS

A trauma registry was used to identify all patients sustaining a gunshot wound (GSW) from July 1, 2015, to June 31, 2016. After excluding deaths during the index admission, clinical demographics, injury characteristics, presence and location of RBF, management, and outcomes, were analyzed.

RESULTS

Overall, 344 patients were admitted for a GSW; of which 298 (86.6%) of these were nonfatal. Of these, 225 (75.5%) had an RBF. During the index admission, 23 (10.2%) had complete RBF removal, 35 (15.6%) had partial, and 167 (74.2%) had no removal. Overall, 202 (89.8%) patients with nonfatal GSW were discharged with an RBF. The primary indication for RBF removal was immediate intraoperative accessibility (n = 39, 67.2%). The most common location for an RBF was in the soft tissue (n = 132, 58.7%). Of the patients discharged with an RBF, mean age was 29.5 years (range, 6.1-62.1 years), 187 (92.6%) were me, with a mean Injury Severity Score of 8.6 (range, 1-75). One hundred sixteen (57.4%) received follow-up, and of these, 13 (11.2%) returned with an RBF-related complication [infection (n = 4), pain (n = 7), fracture nonunion (n = 1), and bone erosion (n = 1)], with a mean time to complication of 130.2 days (range, 11-528 days). Four (3.4%) required RBF removal with a mean time to removal of 146.0 days (range, 10-534 days).

CONCLUSION

Retained bullet fragments are very common after a nonfatal GSW. During the index admission, only a minority are removed. Only a fraction of these are removed during follow-up for complications. As lead toxicity data accumulates, further follow-up studies are warranted.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Twenty-two Years of Pediatric Musculoskeletal Firearm Injuries: Adverse Outcomes for the Very Young

BACKGROUND

Firearm injuries are a significant cause of morbidity and mortality for children in the United States. The purpose of this study is to investigate the 22-year experience of pediatric firearm-related musculoskeletal injuries at a major pediatric level 1 hospital and to analyze the risk of adverse outcomes in children under 10 years of age.

METHODS

An institutional review board-approved, retrospective cohort analysis was conducted on pediatric firearm-related musculoskeletal injuries at our institution from 1995 to 2017. A total of 189 children aged 0 to 18 years were identified using International Classification of Diseases, 9th Revision/10th Revision codes, focusing on musculoskeletal injuries by firearms. Exclusion criteria were primary treatment at an outside hospital, isolated nonmusculoskeletal injuries (eg, traumatic brain injury), and death before orthopaedic intervention. Two cohorts were included: age below 10 years and age 10 years and above. Primary outcome measure was a serious adverse outcome (death, growth disturbance, amputation, or impairment). Standard statistical analysis was used for demographic data, along with linear mixed models and multivariable logistic regression for adverse outcome.

RESULTS

Of the 189 children, 46 (24.3%) were below 10 years of age and 143 (75.7%) were 10 years and above. Fifty-two (27.5%) of the total group had an adverse outcome, with 19 (41.3%) aged below 10 years and 33 (23.1%) aged 10 years and above (P=0.016). Adverse outcomes were 3 deaths, 17 growth disturbances, 7 amputations, and 44 impairments. For those below 10 years of age, rural location (P=0.024), need for surgical treatment (P=0.041), femur injury (P=0.032), peripheral nerve injury (P=0.006), and number of surgeries (P=0.022) were associated with an adverse outcome.

CONCLUSIONS

Over one fourth of survivors of musculoskeletal firearm injuries had an adverse outcome. Children 10 years and above represent the majority of firearm injuries in our population; however, when injured, those below 10 years are more likely to have an adverse outcome.

LEVEL OF EVIDENCE

Level III.

The management of embedded metal fragment patients and the role of chelation Therapy: A workshop of the Department of Veterans Affairs-Walter Reed National Medical Center

Exposure to retained metal fragments from war-related injuries can result in increased systemic metal concentrations, thereby posing potential health risks to target organs far from the site of injury. Given the large number of veterans who have retained fragments and the lack of clear guidance on how to medically manage these individuals, the Department of Veterans Affairs (VA) convened a meeting of chelation experts and clinicians who care for embedded fragment patients to discuss current practices and provide medical management guidance. Based on this group's clinical expertise and review of published literature, the evidence presented suggests that, at least in the case of lead fragments, short-term chelation therapy may be beneficial for embedded fragment patients experiencing acute symptoms associated with metal toxicity; however, in the absence of clinical symptoms or significantly elevated blood lead concentrations (greater than 80 µg/dL), chelation therapy may offer little to no benefit for individuals with retained fragments and pose greater risks due to remobilization of metals stored in bone and other soft tissues. The combination of periodic biomonitoring to assess metal body burden, longitudinal fragment imaging, and selective fragment removal when metal concentrations approach critical injury thresholds offers a more conservative management approach to caring for patients with embedded fragments.

Lead toxicity from retained bullet fragments: A systematic review and meta-analysis

BACKGROUND

Firearm injury remains a public health epidemic in the United States. A large proportion of individuals with gunshot wounds subsequently have retained bullet fragments (RBF). There are no standard medical guidelines regarding bullet removal and the full extent of the consequences of RBF remains unknown.

OBJECTIVE

To determine whether there is an association among RBF, elevated blood lead levels (BLL) and lead toxicity in survivors of firearm injury 16 years and older.

METHODS

PubMed, EMBASE, CINAHL, Scopus, Cochrane Library, and Sociological Abstracts electronic databases were searched for all randomized controlled trials, prospective and retrospective cohort, case-control and cross-sectional studies published in the English language between 1988 and 2018. Quality assessment and risk of bias was evaluated using the Newcastle Ottawa Scale. A meta-analysis was performed using a random-effects model.

RESULTS

The search yielded 2,012 articles after removal of duplicates. Twelve were included after full article review. Eleven studies supported an association between elevated BLL and RBF. Bony fractures were associated with increased risk of elevated BLL in three studies. A positive relationship between BLL and the number of RBF was also shown in three studies, with one study demonstrating 25.6% increase in BLL for every natural-log increase in RBF (1-228, p < 0.01). Meta-analysis demonstrated BLL significantly higher in individuals with RBF as compared to controls (5.47 μg/dL, p < 0.01).

CONCLUSION

Patients with bony fractures or multiple RBF, who are at higher risk of elevated BLL, should be monitored for BLL in intervals of 3 months within the first year of injury. For patients who return with BLL above 5 μg/dL, all efforts must be undertaken to remove fragments if there is no potential to worsen the injury.

LEVEL OF EVIDENCE

Systematic review, Meta-analysis, level III.

Elemental analysis in living human subjects using biomedical devices

Today, patients undergoing dialysis are at low risk for aluminum-induced dementia. Workers are unlikely to experience cadmium-induced emphysema and the public's exposure to lead is an order of magnitude lower than in 1970. The research field of in vivo elemental analysis has played a role in these occupational and environmental health improvements by allowing the effects of people's chronic exposure to elements to be studied using non-invasive, painless, and relatively low-cost technology. From the early 1960s to the present day, researchers have developed radiation-based systems to measure the elemental content of organs at risk or storage organs. This reduces the need for (sometimes painful) biopsy and the risk of infection. Research and development has been undertaken on forty-nine in vivo measurement system designs. Twenty-nine different in vivo elemental analysis systems, measuring 22 different elements, have been successfully taken from design and testing through to human measurement. The majority of these systems employ either neutron activation analysis or x-ray fluorescence analysis as the basis of the measurement. In this review, we discuss eight of the successful systems, explaining the rationale behind their development, the methodology, the health data that has resulted from application of these tools, and provide our opinion on potential future technical developments of these systems. We close by discussing four technologies that may lead to new directions and advances in the whole field.

Effect of bone fracture(s) on blood lead levels from retained lead pellets in craniomaxillofacial region

BACKGROUND

Missile-related blood lead elevations and toxicity are well documented in the literature but reports on its associated risk factor(s) are few.

OBJECTIVE

To determine if bone fracture(s) contribute to an elevated lead blood level.

METHOD

This is a prospective study of subjects with retained pellets in the craniomaxillofacial region following gunshot injuries who met the inclusion criteria. Blood samples were collected from the test subjects and their corresponding control subjects via venipuncture. Collected blood samples were used for blood lead measurement by the wet method of the atomic absorption spectrophotometry. Using appropriate statistical tests, p < 0.05 was considered significant.

RESULTS

A total number of 48 subjects were studied. The mean blood lead levels (BLLs) of the study population were 6.88 ± 1.17 µg/dl while that of the control group was 1.52 ± 0.87 µg/dl and the mean difference was statistically significant (p = 0.03). The mean and standard deviation of BLL of subjects with fractures were 4.77 ± 0.9, 5.08 ± 1.0, and 5.22 ± 1.0 µg/dl at days 3, 21, and 42 postinjury, respectively, while for those without bone fractures were 3.07 ± 1.4, 3.70 ± 0.8, and 4.33 ± 1.7 µg/dl. The difference was statistically significant (p = 0.04).

CONCLUSION

Subjects with bone fractures were found to have higher BLLs than those without bone fractures, where pellets were retained in their bodies.

Examination of metal mobilization from a gunshot by scanning acoustic microscopy, scanning electron microscopy, energy-dispersive X-ray spectroscopy, and inductively coupled plasma optical emission spectroscopy: a case report

BACKGROUND

Projectile foreign bodies are known to cause chronic heavy metal toxicity due to the release of metal into the bloodstream. However, the local effect around the metallic object has not been investigated and the main goal of our study is to examine the influence of the object in close proximity of the object.

CASE PRESENTATION

A 36-year-old Caucasian woman with one metallic pellet close to her sciatic nerve due to a previous shotgun injury at the gluteal area presented with a diagnosis of recurrent lumbar disk herniation at L4-5 level. A physical examination confirmed chronic neuropathy and she underwent a two-stage surgery. The surgery included removal of the foreign body, followed by discectomy and fusion at the involved level. During the removal of the metallic foreign body, a tissue sample around the pellet and another tissue sample from a remote area were obtained. The samples were analyzed by scanning acoustic microscopy, scanning electron microscopy, and energy-dispersive X-ray spectroscopy. Lead, chromium, copper, cadmium, iron, manganese, selenium, and zinc elements in tissue, blood, and serum specimens were detected by inductively coupled plasma optical emission spectroscopy.

CONCLUSIONS

An acoustic impedance map of the tissue closer to the metallic body showed higher values indicating further accumulation of elements. Energy-dispersive X-ray spectroscopy results confirmed scanning acoustic microscopy results by measuring a higher concentration of elements closer to the metallic body. Scanning electron microscopy images showed that original structure was not disturbed far away; however, deformation of the structure existed in the tissue closer to the foreign body. Element analysis showed that element levels within blood and serum were more or less within acceptable ranges; on the other hand, element levels within the tissues showed pronounced differences indicating primarily lead intoxication in the proximity of the metallic body. We can state that residues of metallic foreign bodies of gunshot injuries cause chronic metal infiltration to the surrounding tissue and induce significant damage to nearby neural elements; this is supported by the results of scanning acoustic microscopy, scanning electron microscopy, energy-dispersive X-ray spectroscopy, and inductively coupled plasma optical emission spectroscopy.

Firearm-associated Fractures in Children and Adolescents: Trends in the United States 2003-2012

BACKGROUND

Firearm-associated injuries are the second leading cause of death in children in the United States. Fractures are common comorbid injuries in young patients with firearm-associated injuries. The purpose of this study was to define the burden of firearm-associated fractures (FAFs) in children and adolescents in the United States.

METHODS

We analyzed the 2003-2012 Kids' Inpatient Database. Patients were grouped into 4 age groups: 0 to 4, 5 to 9, 10 to 14, and 15 to 20 years old. Sample observations with both an external cause of injury code indicating gunshot injury and a diagnosis code indicating orthopaedic fracture (extremity, pelvis, or spine) were identified as cases of FAF. Sex, age, race, cause of injury, and fracture-related operating room procedures were catalogued. Population-level incidence was calculated for each year studied.

RESULTS

From 2003 to 2012, the incidence of FAF in patients 20 years and below of age increased from 73 to 96 cases per 100,000 admissions (P=0.009). The 0 to 4 age group saw the largest increase in injury frequency (141%, P=0.08). There was a 4-fold increase in the rate of unintentional injury in this subgroup. The most common age group affected by FAFs was 15 to 20 year olds. Minorities and male individuals were disproportionately affected. Assault and unintentional causes were the most common reasons for injury.

CONCLUSIONS

The frequency of FAF in patients 20 years and below of age increased over the study period, with almost 1 case per 1000 admissions in 2012. The finding that certain subpopulations are disproportionately affected reflects the complex sociologic factors influencing gun violence in the United States.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

High-Precision (MC-ICPMS) Isotope Ratio Analysis Reveals Contrasting Sources of Elevated Blood Lead Levels of an Adult with Retained Bullet Fragments, and of His Child, in Milwaukee, Wisconsin

Exposure to the neurotoxic element lead (Pb) continues to be a major human health concern, particularly for children in US urban settings, and the need for robust tools for assessment of exposure sources has never been greater. The latest generation of multicollector inductively coupled plasma mass spectrometry (MC-ICPMS) instrumentation offers the capability of using Pb isotopic signatures as a tool for environmental source tracking in public health. We present a case where MC-ICPMS was applied to isotopically resolve Pb sources in human clinical samples. An adult male and his child residing in Milwaukee, Wisconsin, presented to care in August 2015 with elevated blood lead levels (BLLs) (>200 μg/dL for the adult and 10 μg/dL for the child). The adult subject is a gunshot victim who had multiple bullet fragments embedded in soft tissue of his thigh for approximately 10 years. This study compared the high-precision isotopic fingerprints (<1 ‰ 2σ external precision) of Pb in the adult's and child's whole blood (WB) to the following possible Pb sources: a surgically extracted bullet fragment, household paint samples and tap water, and a Pb water-distribution pipe removed from servicing a house in the same neighborhood. Pb in the bullet and adult WB were nearly isotopically indistinguishable (matching within 0.05-0.56 ‰), indicating that bullet fragments embedded in soft tissue could be the cause of both acute and chronic elevated blood Pb levels. Among other sources investigated, no single source dominated the child's exposure profile as reflected in the elevated BLL.

Severe lead toxicity attributed to bullet fragments retained in soft tissue

A man aged 30 years presented to an emergency department with a 1 month history of severe abdominal pain, jaundice, constipation, lower extremity weakness and weight loss. A peripheral blood smear was performed that showed basophilic stippling of erythrocytes prompting a blood lead level (BLL) evaluation. The patient had a BLL of >200 µg/dL. Retained bullet fragments were identified in the left lower extremity from a previous gunshot wound 10 years prior. Lead from the excised bullet fragment was consistent with the patient's blood lead by isotope ratio analysis. This case is a rare example of a severely elevated BLL attributed to bullet fragments in soft tissue. Bullets retained in soft tissue are not often considered a risk factor for a markedly elevated BLL because they become encapsulated within the tissue over time.

Firearm-related Musculoskeletal Injuries in Children and Adolescents

Firearm injuries are a major cause of morbidity and mortality among children and adolescents in the United States and take financial and emotional tolls on the affected children, their families, and society as a whole. Musculoskeletal injuries resulting from firearms are common and may involve bones, joints, and neurovascular structures and other soft tissues. Child-specific factors that must be considered in the setting of gunshot injuries include physeal arrest and lead toxicity. Understanding the ballistics associated with various types of weaponry is useful for guiding orthopaedic surgical treatment. Various strategies for preventing these injuries range from educational programs to the enactment of legislation focused on regulating guns and gun ownership. Several prominent medical societies whose members routinely care for children and adolescents with firearm-related injuries, including the American Academy of Pediatrics and the American Pediatric Surgical Association, have issued policy statements aimed at mitigating gun-related injuries and deaths in children. Healthcare providers for young patients with firearm-related musculoskeletal injuries must appreciate the full scope of this important public health issue.

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.

[Left ventricular projectile migration after an accidental close-range gunshot wound]

We report the case of a 24-year-old female after sustaining a shotgun wound in the left upper extremity and chest. Initial emergency diagnostics revealed numerous shotgun pellets scattered throughout the left-side soft tissue, chest and upper lung lobe with one pellet having migrated into the left ventricle of the heart.Due to the devastating injury pattern, gunshot wounds are interdisciplinarily challenging and should include extended initial diagnostics, such as contrast agent CT. The potential toxicity of elevated lead blood levels have to be taken into further account.

Retained Lumbar Bullet: A Case Report of Chronic Lead Toxicity and Review of the Literature

BACKGROUND

Lead toxicity from retained bullet fragments is difficult to both predict and diagnose, but important to treat early, given the potential severity of disease. Blood lead levels > 25 μg/dL and 40 μg/dL are considered toxic in children and adults, respectively. Symptoms may range from nonspecific constitutional symptoms to seizures and coma. Chelation is the mainstay therapy for lead poisoning and levels to treat depend on patient age, blood lead levels, and the presence of symptoms. CASE 

REPORT

We present the case of a woman with symptoms of severe lead toxicity from 20-year-old retained bullet fragments. She had been seen by multiple providers for evaluation of each symptom, but a unifying diagnosis had not been found. After identifying this complication, she was treated appropriately and more serious complications were prevented. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of lead toxicity in patients with a seemingly unrelated constellation of symptoms and a history of a previous gunshot wound with retained bullet or bullet fragments.

[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.

Retained bullet removal in civilian pelvis and extremity gunshot injuries: a systematic review

BACKGROUND

Although gunshot injuries are relatively common, there is little consensus about whether retained bullets or bullet fragments should be removed routinely or only in selected circumstances.

QUESTIONS/PURPOSES

We performed a systematic review of the literature to answer the following questions: (1) Is bullet and/or bullet fragment removal from gunshot injuries to the pelvis or extremities routinely indicated? And, if not, (2) what are the selected indications for removal of bullets and/or bullet fragments?

METHODS

A search of the English-language literature on the topic of gunshot injury and bullet removal was performed using the National Library of Medicine and MEDLINE(®) and supplemented by hand searching of bibliographies of included references. Studies were included if they provided clinical data on one or both of our study questions; included studies were evaluated using the levels of evidence rubric. Most studies on the subject were expert opinion (Level V evidence), and these were excluded; one Level III study and seven Level IV studies were included.

RESULTS

No studies provided a rationale for routine bullet removal in all cases. The studies identified bullet fragment removal as indicated acutely for those located within a joint, the palm, or the sole. Chronic infection, persistent pain at the bullet site, and lead intoxication were reported as late indications for bullet removal.

CONCLUSIONS

The evidence base for making clinical recommendations on the topic of bullet and bullet fragment removal after gunshot injury is weak. Level I and II evidence is needed to determine the indications for bullet removal after gunshot injury.

Treatment strategy in a child with a retained bullet in the cerebellomedullary cistern

A 6-year-old girl was admitted to our emergency room because of a gunshot wound in the posterior craniocervical junction. On admission, she was alert, but left hemiplegia and right hemiparesis were noted. Cranial CT scanning showed a retained bullet in the cerebellomedullary cistern without bone destruction. Moreover, fourth ventricle hemorrhage was observed. There were no signs of acute hydrocephalus. The patient underwent suboccipital craniectomy and C-1 laminectomy for bullet removal. Postoperatively, the patient experienced significant neurological improvement. To the best of the authors' knowledge, this is the first documented case of a patient with a retained bullet in the cerebellomedullary cistern. The management strategies in such a unique case are discussed.

Treatment of chronic lead toxicity with succimer: a case series of 2 adults with retained lead shotgun fragments

Few recommendations exist for management of chronic lead toxicity in instances when the source of lead exposure cannot be removed.

CASES

We describe 2 patients who had shotgun wounds resulting in multiple retained lead pellets. They developed elevated blood lead levels and were treated with 2 weeks of high-dose oral succimer before being placed on maintenance oral succimer therapy with the goal of sustaining suppressed lead levels.

DISCUSSION

Retained lead pellets have been associated with increasing blood lead levels over time. Chronic lead toxicity can cause significant morbidity. Few treatments for lead toxicity are available, and there is scarce data on maintenance therapy for patients who have large numbers of retained shotgun pellets.

CONCLUSIONS

This case series documents 2 patients who continue on maintenance oral chelation therapy with succimer in an effort to prevent the sequelae of chronic lead toxicity by maintaining blood lead levels less than 20 μg/dL.

The role of maxillofacial radiologists in gunshot injuries: a hypothesized missile trajectory in two case reports

Gunshot injuries are an emerging form of trauma that oral radiologists increasingly have to deal with. There are two main types of gunshot injuries: high-velocity and low-velocity bullet injuries. The outcome of high-velocity gunshot injury is usually fatal; however, a non-fatal low-velocity injury to the maxillofacial region is more likely to be encountered by the oral and maxillofacial radiologist. It is therefore important to up-to-date knowledge of ballistic science and its implications in the field of maxillofacial radiology. The ability of oral and maxillofacial radiologists to predict the missile trajectory will aid the assessment and localization of the damage caused by the bullet and its splinters. Predicting the missile trajectory may also be of help to law enforcement agencies and forensic scientists in determining the type of firearm used and direction of fire. This article, which examines two cases, attempts to highlight to the oral radiologist this emerging form of trauma and its implications.

Extreme gastric dilation caused by chronic lead poisoning: A case report

Lead is a toxic metal that affects many organ systems and functions in humans. In the majority of adults, chronic lead poisoning comes from exposures to work places and can occur in numerous work settings, such as manufacturing, lead smelting and refinement, or due to use of batteries, pigments, solder, ammunitions, paint, car radiators, cable and wires, certain cosmetics. In some countries, lead is added to petrol. We present a rare case of gastric dilation caused by long-term petrol ingestion. A 16-year-old young man was admitted to our hospital due to a 6-mo history of exhaustion, dizziness, nausea, abdominal cramps and constipation. X-ray examination revealed dilated stomach descending into the pelvis and small bowel distension. After a long clinical observation, we found that the reason for the chronic lead poisoning of the patient was due to a 3-year history of petrol ingestion. The patient spontaneously recovered and stomach returned to its normal position and size. Lead poisoning should be taken into consideration in all unexplained cases of gastric dilation.

Lead toxicity in a 14-year-old female with retained bullet fragments

In the past 3 decades, lead levels in North American children have been declining. Despite the decline in lead exposure, lead toxicity remains a significant childhood environmental health hazard. The usual route of lead exposure is through ingestion, but lead toxicity secondary to retained bullet fragments has been well documented in the adult literature. The diagnosis of lead toxicity is often difficult and delayed secondary to vague and transient symptoms. Recognizing high-risk characteristics of bullet fragments can improve clinician awareness to the possibility of lead toxicity. The primary management of patients with continued lead exposure is to remove the source of exposure. However, in the case of retained bullet fragments, initiation of chelation therapy before surgical removal may be essential in preventing systemic toxicity. We present the case of a 14-year-old female with lead toxicity who presented with an 18-month course of chronic abdominal pain, vomiting, and anorexia 2 years after sustaining a gunshot wound to the right leg. The patient was treated with oral succimer and operative removal of bullet fragments.

Elevation of Blood Lead Levels in Emergency Department Patients with Extra-articular Retained Missiles

BACKGROUND

Patients who survive gunshot wounds often have retained missiles. Unlike intra-articular retained missiles, extra-articular retained missiles (EARMs) are not routinely removed. Cases of lead toxicity from EARMs have been described. This study seeks to determine whether blood lead levels are elevated in emergency department patients with EARMs compared with matched controls, whether clinical symptoms of lead toxicity are more prevalent in patients with EARMs than in controls, and whether longer missile retention times or recent hypermetabolic conditions are associated with higher blood lead levels.

METHODS

One hundred twenty adults with EARMs and 120 age- and gender-matched controls with no history of gunshot wound were prospectively enrolled on presentation to a large urban emergency department. Whole blood lead (WBL), zinc protoporphyrin, and hemoglobin levels were obtained. Patients completed a questionnaire regarding time since gunshot injury; symptoms of lead toxicity; and occurrence within 30 days of any surgery, alcohol abuse, illicit drug abuse, diabetic ketoacidosis, hyperthyroidism, infection, fracture, pregnancy, or lactation.

RESULTS

Five EARM patients (4%) and no control patients (0%) had WBL greater than our threshold for medical follow-up (20 microg/dL). Mean WBL was 6.71 microg/dL (95% confidence interval [CI], 5.68-7.74 microg/dL) in EARM patients and 3.16 mug/dL (95% CI, 2.79-3.53 microg/dL) in controls. This difference was statistically significant when analyzed by matched pairs t test (p = 0.0001). There was no difference in the number of symptoms associated with lead toxicity that were noted by EARM patients versus controls (p = 0.377). Longer duration of missile retention was not associated with higher blood lead levels (r = 0.125, p = 0.172). Of the five hypermetabolic conditions analyzed, only fractures were associated with elevated blood lead levels (9.95 microg/dL [95% CI, 5.77-14.13 microg/dL] in EARM patients with fractures vs. 6.23 microg/dL [95% CI, 5.23-7.23 microg/dL] in EARM patients without fractures).

CONCLUSION

Patients with EARMs have significantly elevated blood lead levels compared with matched controls. The occurrence of a bony fracture within the past 30 days is associated with a higher lead level. In 96% of patients with EARMs, elevated lead levels were not clinically significant and did not change patient management.

Does lead interfere with hemoglobin-based oxygen carrier (HBOC) function? A pilot study of lead concentrations in three approved or tested HBOCs and oxyhemoglobin dissociation with HBOCs and/or bovine blood with varying lead concentrations

We measured lead concentrations in three hemoglobin-based oxygen carriers (HBOCs; Oxyglobin, Hemopure, and Hemolink) and compared them with lead concentrations from blood-bank blood. Oxyhemoglobin dissociation was measured with large concentrations of lead in bovine HBOC, with or without bovine blood, and in bovine blood. Samples of each were prepared by combining one with normal saline (control), the second with small lead concentrations (22 micro g/dL), and the third with toxic lead concentrations (70 micro g/dL). They were blended in 2 tonometers at oxygen concentrations (2.5%, 5%, 8%, 10%, 21%, and 95%) with 5% CO(2) and the remainder nitrogen for 5 min per sample after a 15-min wash-in with each level of oxygen and were measured with co-oximetry. Oxygen saturation was plotted against PO(2), fitting fourth-order polynomial nonlinear regression to the data. The lead concentrations of the three HBOCs were 0.51, 0.22, 0.40 micro g/dL. There were no clinically important differences of the oxyhemoglobin dissociation curves as a function of lead concentration. The lead concentrations of the three tested HBOCs were small and no larger than the average for blood-bank blood. The presence of increasing concentrations of lead in either concentrated solution of bovine HBOC or a 1:1 mixture of bovine HBOC and native bovine blood does not appear to affect hemoglobin oxygenation in an acute in vitro model of increased lead concentrations.

IMPLICATIONS

Gunshot wounds rapidly increase circulating lead concentrations. Lead concentrations are small in three hemoglobin-based oxygen carriers (HBOCs), and HBOCs and/or bovine blood do not appear to be affected by lead concentrations in terms of immediate oxygen on-loading and off-loading. HBOCs may be useful in patients with gunshot wounds.

Elevated blood lead resulting from maxillofacial gunshot injuries with lead ingestion

PURPOSE

The purpose of this study was to identify the contribution of ingested lead particles to elevated blood lead concentrations in victims of gunshot injury to the maxillofacial region.

PATIENTS AND METHODS

As part of a larger study of the effects of retained lead bullets on blood lead, a retrospective review of study findings was completed on 5 of 8 patients who sustained injuries to the maxillofacial region. These 5 patients were recruited into the larger study within 11 days of injury and showed a penetration path for the projectile that engaged the upper aerodigestive tract. All subjects were recruited from patients presenting for care of their gunshot injuries to a large inner-city trauma center with a retained bullet resulting from a gunshot injury. An initial blood lead level was measured for all recruited patients and repeated 1 to 17 weeks later. Medical history was taken along with a screening and risk factor questionnaire to determine other potential or actual sources (occupational/recreational) of lead exposure. (109)Cd K-shell x-ray fluorescence determinations of bone lead were completed to determine past lead exposure not revealed by medical history and risk factor questionnaire. Radiographs taken of the abdomen and chest, required as a part of the patient's hospital care, were retrospectively reviewed for signs of metallic fragments along the aerodigestive tract.

RESULTS

All 5 patients retained multiple lead pellets or fragments at the site of injury, sustained fractures of the facial bones, and showed increases in blood lead. Three of the 5 study subjects who sustained maxillofacial gunshot injuries involving the mouth, nose, or throat region showed metallic densities along the gastrointestinal tract indicative of ingested bullet fragments. Each patient with ingested bullet fragments showed rapid elevation of blood lead exceeding 25 microg/dL and sustained increases well beyond the time when all ingested fragments were eliminated. A 3-year follow-up on these 3 patients showed significantly sustained elevation of blood lead but less than that observed during the initial 6 months after injury. None of the 5 study subjects showed any evidence of metallic foreign bodies within the tracheobronchial regions indicative of aspiration.

CONCLUSION

Ingestion of lead fragments can result from gunshot injuries to the maxillofacial region and may substantially contribute to a rapid increase in blood lead level. Prompt diagnosis and elimination of ingested lead fragments are essential steps necessary to prevent lead being absorbed from the gastrointestinal tract. Increased blood lead in victims after gunshot injuries must be fully evaluated for all potential sources, including recent environmental exposure, absorption of lead from any remaining bullets in body tissues, and the possibility of mobilization of lead from long-term body stores such as bone.

Corrections to "How to calculate lead concentration and concentration uncertainty in XRF in vivo bone lead analysis" by Kondrashov and Rothenberg

Kondrashov and Rothenberg (Appl. Radiat. Isot. 55 (2001) 799) have published "a substantial correction for calculating estimates of lead concentration and uncertainty for in vivo X-ray fluorescent bone analysis with Cd-109 source" (sic). Our paper shows that their correction fails to consider two important points that render it (i) a correction to a superseded method and (ii) of limited effect. Also, their approach to a "crude" estimate produces measurement uncertainties that are implausibly small. In order that they not be propagated in the literature, our paper also corrects several misstatements and errors in Kondrashov and Rothenberg.