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Russell N, Vieira EJ, Freeman LR, Eastman AL, Khan U, Schluterman HM, Beakes C, Kirkpatrick S, Grant JL. Diagnostic and therapeutic considerations in cases of civilian intravascular ballistic embolism: a review of case reports. Trauma Surg Acute Care Open 2024; 9:e001390. [PMID: 39005707 PMCID: PMC11243208 DOI: 10.1136/tsaco-2024-001390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 06/20/2024] [Indexed: 07/16/2024] Open
Abstract
Background Ballistic embolism (BE) is a rare complication of firearm injuries notoriously associated with a vexing clinical picture in the trauma bay. Unless considered early, the associated confusion can lead to needless delay in the management of the patient with a gunshot wound. Despite this known entity, there is a relative paucity of high-grade evidence regarding complications, management, and follow-up in these patients. Methods An electronic database literature search was conducted to identify cases of acute intravascular BE in pediatric and adult civilians occurring during index hospitalization, filtered to publications during the past 10 years. Exclusion criteria included non-vascular embolization, injuries occurring in the military setting, and delayed migration defined as occurring after discharge from the index hospitalization. Results A total of 136 cases were analyzed. Nearly all cases of BE occurred within 48 hours of presentation. Compared with venous emboli, arterial emboli were significantly more likely to be symptomatic (71% vs. 7%, p<0.001), and 43% of patients developed symptoms attributable to BE in the trauma bay. In addition, arterial emboli were significantly less likely to be managed non-invasively (19% vs. 49%, p<0.001). Open retrieval was significantly more likely to be successful compared with endovascular attempts (91% vs. 29%, p<0.001). Patients with arterial emboli were more likely to receive follow-up (52% vs. 39%) and any attempt at retrieval during the hospitalization was significantly associated with outpatient follow-up (p=0.034). All but one patient remained stable or had clinically improved symptoms after discharge. Conclusion Consideration for BE is reasonable in any patient with new or persistent unexplained signs or symptoms, especially during the first 48 hours after a penetrating firearm injury. Although venous BE can often be safely observed, arterial BE generally necessitates urgent retrieval. Patients who are managed non-invasively may benefit from follow-up in the first year after injury.
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Affiliation(s)
- Nicole Russell
- Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, Texas, USA
| | - Ethan J Vieira
- Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, Texas, USA
| | - Lexi R Freeman
- Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, Texas, USA
| | - Alexander L Eastman
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Uzer Khan
- Department of Surgery, Texas Health Harris Methodist Hospital Fort Worth, Fort Worth, Texas, USA
- Department of Surgery, Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, TX, USA
| | - Haley M Schluterman
- Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, Texas, USA
| | - Caroline Beakes
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Sioned Kirkpatrick
- Department of Surgery, Texas Health Harris Methodist Hospital Fort Worth, Fort Worth, Texas, USA
| | - Jennifer L Grant
- Department of Surgery, Texas Health Harris Methodist Hospital Fort Worth, Fort Worth, Texas, USA
- Department of Surgery, Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, TX, USA
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Do A, Garzelli L, Garnier R, Court C, Sellam J, Miquel A, Berenbaum F. Inflammatory low back pain with radiculopathy revealing epidural disintegration of a bullet complicated by lead poisoning. RMD Open 2023; 9:e003119. [PMID: 38088246 PMCID: PMC10711883 DOI: 10.1136/rmdopen-2023-003119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/14/2023] [Indexed: 12/18/2023] Open
Abstract
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.
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Affiliation(s)
- Ariane Do
- Department of Rheumatology, Hospital Saint-Antoine, Paris, France
- Sorbonne University, Paris, France
| | | | - Robert Garnier
- Toxicovigilance Center, Hospital Fernand-Widal, Paris, France
| | - Charles Court
- Department of Orthopedic and Traumatology Surgery, Hospital Bicetre, Le Kremlin-Bicetre, France
- Paris-Saclay University, Gif-sur-Yvette, France
| | - Jérémie Sellam
- Department of Rheumatology, Hospital Saint-Antoine, Paris, France
- Sorbonne University, Paris, France
| | - Anne Miquel
- Department of Radiology, Hospital Saint-Antoine, Paris, France
| | - Francis Berenbaum
- Department of Rheumatology, Hospital Saint-Antoine, Paris, France
- Sorbonne University, Paris, France
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Costantini I, Carollo M, Losso L, Morando E, Bacchion M, Mantelli G, Pizzuto M, Spagnuolo L, Ventura MV, Ricci G. "Heavy Metal": Management of lead toxicity following a gunshot injury with retained lead fragments, a case report. Toxicol Rep 2023; 11:444-448. [PMID: 38021473 PMCID: PMC10665592 DOI: 10.1016/j.toxrep.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/30/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023] Open
Abstract
There is limited literature on managing chronic lead exposure from non-removable sources such as lead fragments. In this case report, we present the complexities and clinical considerations involved in treating an elderly patient who sustained a comminuted knee fracture due to a gunshot wound, complicated by retained lead fragments. This case highlights the absence of comprehensive guidelines for managing chronic lead exposure when complete fragment removal is impractical. It also emphasizes the importance of a multidisciplinary approach to decision-making, while considering patient autonomy in such unique clinical scenarios.
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Affiliation(s)
- Ilaria Costantini
- USD Poison Control Center, Azienda Ospedaliera Universitaria integrata, Verona, Italy
| | - Massimo Carollo
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Lorenzo Losso
- Department of Medical Toxicology Unit and Poison Control Centre, University of Florence, Florence, Italy
| | - Elia Morando
- USD Poison Control Center, Azienda Ospedaliera Universitaria integrata, Verona, Italy
| | - Matilde Bacchion
- USD Poison Control Center, Azienda Ospedaliera Universitaria integrata, Verona, Italy
| | - Giovanni Mantelli
- USD Poison Control Center, Azienda Ospedaliera Universitaria integrata, Verona, Italy
| | - Mauro Pizzuto
- Department of Medicine, University of Verona, Verona, Italy
| | | | | | - Giorgio Ricci
- USD Poison Control Center, Azienda Ospedaliera Universitaria integrata, Verona, Italy
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Twardy SM, Hanson SM, Jursa T, Gaitens JM, Kalinich JM, McDiarmid MA, Smith DR. Succimer chelation does not produce lasting reductions of blood lead levels in a rodent model of retained lead fragments. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2023; 104:104283. [PMID: 37775076 DOI: 10.1016/j.etap.2023.104283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/20/2023] [Accepted: 09/23/2023] [Indexed: 10/01/2023]
Abstract
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.
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Affiliation(s)
- Shannon M Twardy
- Department of Microbiology and Environmental Toxicology, University of California, Santa Cruz, CA, USA
| | - Sarah M Hanson
- Department of Microbiology and Environmental Toxicology, University of California, Santa Cruz, CA, USA
| | - Thomas Jursa
- Department of Microbiology and Environmental Toxicology, University of California, Santa Cruz, CA, USA
| | - Joanna M Gaitens
- Division of Occupational and Environmental Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - John M Kalinich
- Division of Occupational and Environmental Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melissa A McDiarmid
- Division of Occupational and Environmental Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Don R Smith
- Department of Microbiology and Environmental Toxicology, University of California, Santa Cruz, CA, USA.
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Mehl SC, Moturu A, Miranda J, Mills J, Rosenfeld E, Stapleton G, Naik-Mathuria B. Management of Pediatric Aortic Pseudoaneurysm Due to Penetrating Trauma. Am Surg 2023; 89:5024-5026. [PMID: 37496491 DOI: 10.1177/00031348231192071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Due to the increasing frequency of pediatric penetrating trauma, pediatric surgeons need to be prepared to evaluate and manage complex penetrating injuries. In this report, we discuss the endovascular management of a traumatic aortic pseudoaneurym and subsequent bullet retrieval following penetrating chest trauma in a child. The key to successful management included multidisciplinary decision making and use of an expandable covered stent generally used for management of aortic coarctation.
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Affiliation(s)
- Steven C Mehl
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Anoosha Moturu
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jorge Miranda
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Surgery, Division of Vascular Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Joseph Mills
- Department of Surgery, Division of Vascular Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Eric Rosenfeld
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Gary Stapleton
- Department of Pediatrics, Division of Pediatric Cardiology, Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Bindi Naik-Mathuria
- Department of Surgery, Division of Pediatric Surgery, University of Texas Medical Branch, Galveston, TX, USA
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Cubello J, Peterson DR, Wang L, Mayer-Proschel M. Maternal Iron Deficiency and Environmental Lead (Pb) Exposure Alter the Predictive Value of Blood Pb Levels on Brain Pb Burden in the Offspring in a Dietary Mouse Model: An Important Consideration for Cumulative Risk in Development. Nutrients 2023; 15:4101. [PMID: 37836385 PMCID: PMC10574741 DOI: 10.3390/nu15194101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Maternal iron deficiency (ID) and environmental lead (Pb) exposure are co-occurring insults that both affect the neurodevelopment of offspring. Few studies have investigated how ID affects brain-region-specific Pb accumulations using human-relevant Pb concentrations. Furthermore, how these Pb exposures impact blood and brain Fe levels remains unclear. Importantly, we also wanted to determine whether the use of blood Pb levels as a surrogate for the brain Pb burden is affected by underlying iron status. We exposed virgin Swiss Webster female mice to one of six conditions differing by iron diet and Pb water concentration (0 ppm, 19 ppm, or 50 ppm lead acetate) and used Inductively Coupled Plasma Mass Spectrometry to measure the maternal and offspring circulating, stored, and brain Pb levels. We found that maternal ID rendered the offspring iron-deficient anemic and led to a region-specific depletion of brain Fe that was exacerbated by Pb in a dose-specific manner. The postnatal iron deficiency anemia also exacerbated cortical and hippocampal Pb accumulation. Interestingly, BPb levels only correlated with the brain Pb burden in ID pups but not in IN offspring. We conclude that ID significantly increases the brain Pb burden and that BPb levels alone are insufficient as a clinical surrogate to make extrapolations on the brain Pb burden.
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Affiliation(s)
- Janine Cubello
- Department of Environmental Medicine, University of Rochester, Rochester, NY 14642, USA;
| | - Derick R. Peterson
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY 14642, USA; (D.R.P.); (L.W.)
| | - Lu Wang
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY 14642, USA; (D.R.P.); (L.W.)
| | - Margot Mayer-Proschel
- Department of Biomedical Genetics, University of Rochester, Rochester, NY 14642, USA
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Smith RN, Nedergaard RM, Meyer CH, DeSousa N, Ghosh M, Blount Q, Apte A, Resnick S, Hennink MM. Psychological Impacts of Retained Bullets From the Perspective of Survivors. Am Surg 2023; 89:3732-3738. [PMID: 37148273 PMCID: PMC10725717 DOI: 10.1177/00031348231171121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
INTRODUCTION Despite a high prevalence of retained bullet fragments (RBFs) after firearm related injury (FRI) there is limited data on the full spectrum of their consequences, particularly the psychological impacts on those injured. Further, the experiences of FRI survivors with RBFs are missing from existing literature. The objective of this study was to explore the psychological impacts of RBFs on individuals who have experienced recent FRI. METHODS Adult (18-65 years) survivors of FRI with radiographically confirmed RBFs were purposively selected from an urban Level 1 trauma center in Atlanta, Georgia, to participate in an in-depth interview. Interviews were conducted between March 2019 and February 2020. Thematic analysis was used to identify a range of psychological effects from RBFs. RESULTS Interviews from 24 FRI survivors were analyzed: the majority of participants were Black males (N = 22, 92%) with a mean age of 32 years whose FRI occurred ∼8.6 months prior to data collection. The psychological effects of RBFs were grouped into four categories: physical health (eg, pain, limited mobility), emotional well-being (eg, anger, fear), social isolation, and occupational welfare (eg, disability leading to inability to work). A range of coping mechanisms were also identified. CONCLUSION Survivors of FRI with RBFs experience a range of psychological impacts that are far-reaching and affect daily activities, mobility, pain and emotional wellbeing. Study results indicate a need for enhanced resources to support those with RBFs. Further, changes to clinical protocols are warranted on removal of RBFs and communication about the effects of leaving RBFs in situ.
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Affiliation(s)
- R. N. Smith
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - R. M. Nedergaard
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
- National Health Service, South East London, England, UK
| | - C. H. Meyer
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - N. DeSousa
- Emory University School of Medicine, Atlanta, GA, USA
| | - M. Ghosh
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Q. Blount
- Emory University School of Medicine, Atlanta, GA, USA
| | - A. Apte
- Emory University School of Medicine, Atlanta, GA, USA
| | | | - M. M. Hennink
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
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8
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Sarber KM, O'Connor P, Weitzel EK, Stevens J, Aden JK, Breeze J. Local Effect of Ballistic Fragments Embedded Along the Carotid Sheath of a Porcine Animal Model. Mil Med 2023; 188:e1774-e1780. [PMID: 36173120 DOI: 10.1093/milmed/usac276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/14/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Energized ballistic fragments from improvised explosive devices were the most common cause of injury to coalition service personnel during conflicts in Iraq and Afghanistan. Surgical excision of retained fragments is not routinely performed unless there is a concern for injury to vital structures. However, no clear guidelines dictate when or if a fragment should be removed, reflecting a lack of objective evidence of their long-term effects. Using a porcine model, we aimed to evaluate changes to the carotid artery produced by retained fragments over time. MATERIALS AND METHODS Institutional Animal Care and Use Committee approval for all experiments was obtained before commencement of the study. Eighteen female swine (mean mass 62.0 ± 3.4 kg) were randomized into three study groups corresponding to the time of survival after implantation of ballistic fragments: 1, 6, and 12 weeks. Two animals from each group were randomly assigned to have one of the three different fragments implanted within the right carotid sheath in zones 1-3 of the neck. The left carotid served as the control. The vascular flow rate and arterial diameter were measured at each level before implantation and again after the survival interval. Baseline and interval angiograms were performed to identify gross vascular changes. RESULTS No abnormalities were identified on baseline or interval angiograms. No significant difference was found when the baseline was compared to interval measurements or when compared to the control side for all gross and physiological measures at 1 and 6 weeks (P = .053-.855). After 12 weeks, the flow and diameter changed significantly (P < .001-.03), but this significant change was found in both the control and affected carotid. CONCLUSIONS The lack of significant gross anatomical and physiological changes at 6 weeks postimplantation lends evidence toward the current policy that early removal of retained ballistic fragments around cervical vessels is not required. Changes were significant after 12 weeks which suggest that surveillance may be required; however, such changes could be explained by physiological animal growth.
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Affiliation(s)
- Kathleen M Sarber
- Department of Surgery, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Otolaryngology-Head and Neck Surgery, 59th Medical Group, Lackland AFB, TX 78236, USA
| | - Peter O'Connor
- Department of Otolaryngology, Mid Coast Hospital - MaineHealth, Brunswick, ME 04011, USA
| | - Erik K Weitzel
- Department of Surgery, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Operational Medicine, Wilford Hall Ambulatory Surgical Center, Lackland AFB, TX 78236, USA
| | - Jayne Stevens
- Department of Otolaryngology-Head and Neck Surgery, 59th Medical Group, Lackland AFB, TX 78236, USA
| | - James K Aden
- Department of Graduate Medical Education, Brooke Army Medical Center, Ft Sam Houston, TX 78234, USA
| | - John Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Level 2 Queen Elizabeth Hospital, Birmingham B15 2TH, UK
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Wang B, Yang L, Yuan J, Qin W, Wu P, Yang X, Hou G, Yu M, Gong X, Xu Z, Qin J, Gao X, Ma S, Wang F. Percutaneous nephroscopy combined with the laser used for right kidney bullet extraction: A case report. Medicine (Baltimore) 2023; 102:e32841. [PMID: 36820590 PMCID: PMC9907987 DOI: 10.1097/md.0000000000032841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
RATIONALE Wounds caused by firearms are intractable problems in treating war traumas and clinical management. Conventional open surgery inflicts large injury and leads to slow recovery. At the same time, most patients suffer from compound injuries with the critical condition and poor operation tolerance. Thus, it is crucial to probe into the minimally invasive surgical removal of residual kidney bullets. PATIENT CONCERNS We report a case where a bullet remained in the right renal parenchyma on the patient, with penetrating injury in his liver. DIAGNOSIS Obviously the patient has suffered gunshot wound with a bullet stuck in his kidney, while his liver function was impacted. INTERVENTIONS Six months after the injury, we performed the minimally-invasive procedures on the patient with percutaneous nephroscope technology and laser technology under the guidance of ultrasound localization. The bullet and ammunition granulation and scar surrounding tissue were fully removed. Intraoperative bleeding was little, while the incision was small. The patient could leave the bed and walk on the 1st postoperative day. The drainage tube was removed on the 3rd postoperative day, after which the patient was discharged on the 4th postoperative day. OUTCOMES The patient recovered well after surgery and was followed up for 5 years. The latest examination of his liver and kidney function was as follows: alanine aminotransferase 61IU/L, aspartate aminotransferase 33 IU/L, albumin/globulin 46.6/26.0, total bilirubin 19.1μmol/L, direct bilirubin 4.9μmol/L, indirect bilirubin 14.2μmol/L, alkaline phosphatase 111 IU/L, creatinine 57μmol/L, urea 5.16mmol/L, cystatin 0.73mg/L. The plain computed tomography scan showed a few calcifications in the liver and a patchy low-density shadow in the right kidney. It was proved that the liver and kidney function of the patient recovered well, and his living qualify has come back to the track, with no postoperative complications. LESSONS Innovative integration of percutaneous nephroscopy technology and laser was used to remove kidney foreign bodies and developed the optimal surgical plan, small trauma, fast recovery, and the treatment of kidney foreign bodies was newly explored.
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Affiliation(s)
- Baolong Wang
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Lijun Yang
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Jianlin Yuan
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Weijun Qin
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Peng Wu
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xiaojian Yang
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Guangdong Hou
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Ming Yu
- Department of Ultrasound, Xi’an Daxing Hospital, Shaanxi University of Chinese Medicine, Xi’an, China
| | - Xue Gong
- Department of Ultrasound, Xi’an Daxing Hospital, Shaanxi University of Chinese Medicine, Xi’an, China
| | - Zhicheng Xu
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Jun Qin
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xuelin Gao
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Shuaijun Ma
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Fuli Wang
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- * Correspondence: Fuli Wang, Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi’an 710032, China (e-mail: )
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10
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Cingoz ID, Kaya I, Sahin MC, Kilcarslan B, Yuceer N. Spine and spinal cord injuries in Syria war: treatment and outcome. Spinal Cord 2023; 61:169-174. [PMID: 36575225 DOI: 10.1038/s41393-022-00870-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/28/2022]
Abstract
STUDY DESIGN This was a retrospective, comparative 6-year study. OBJECTIVES This study aimed to retrospectively analyze patients who were treated at Kilis State Hospital for spine and spinal cord injuries during the Syrian civil war and to compare the treatment results with the literature. SETTING Kilis State Hospital, Kilis, Turkey. METHODS In our study, 84 patients who were treated for spine and spinal cord injuries between December 2011 and May 2017 were examined. Patient age, sex, injury type, injury region, neurological status, time from injury to treatment, treatment methods, surgical methods applied, and complications were evaluated. RESULTS Of the patients, 72 were male, and 12 were female. The mean age of the patients was 23.2 ± 7.3 years. Fifty-two patients were treated surgically. Surgical treatment was applied to 44 patients with neurological deficits. At least 1-grade neurological improvement was observed in 77.3% (n = 34) of patients with neurological deficits who underwent surgical treatment. Surgical treatment was performed on 18 (34.6%) patients in the first 24 h, 27 (51.9%) patients within 24-72 h, and 7 patients (13.5%) between 72 h and 5 days. Neurological improvement was observed in all patients with neurological deficits who underwent surgical treatment in the first 24 h. CONCLUSIONS Early surgery (in the first 24 h) had a positive effect on the neurological recovery of the patients in our study. Thus, patients with spine and spinal cord injuries rendered a surgical-treatment decision should be operated on in a timely manner, particularly within the first 24 h.
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Affiliation(s)
- Ilker D Cingoz
- Department of Neurosurgery, Faculty of Medicine, Usak University, Usak, Turkey.
| | - Ismail Kaya
- Department of Neurosurgery, Faculty of Medicine, Usak University, Usak, Turkey
| | - Meryem C Sahin
- Department of Medical Services and Techniques, Vocational School of Health Services, Usak University, Usak, Turkey
| | - Bilal Kilcarslan
- Department of Neurosurgery, Denizli State Hospital, Denizli, Turkey
| | - Nurullah Yuceer
- Department of Neurosurgery, Faculty of Medicine, Izmir Katip Çelebi University, Izmir, Turkey
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11
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Ditkofsky N, Nair JR, Frank Y, Mathur S, Nanda B, Moreland R, Rotman JA. Understanding Ballistic Injuries. Radiol Clin North Am 2023; 61:119-128. [DOI: 10.1016/j.rcl.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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12
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Aaronson DM, Awad AJ, Hedayat HS. Lead toxicity due to retained intracranial bullet fragments: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE21453. [PMID: 36164673 PMCID: PMC9514260 DOI: 10.3171/case21453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 07/08/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Lead toxicity (plumbism) secondary to retained lead bullet fragments is a rare complication in patients with gunshot wounds. To the authors' knowledge, there has been no definitive case reported of lead toxicity due to retained intracranial bullet fragments. OBSERVATIONS The authors reported the case of a 23-year-old man who presented after being found down. Computed tomography scanning of the head revealed bullet fragments within the calvaria adjacent to the left transverse sinus. During follow-up, he developed symptoms of plumbism with paresthesias in his bilateral hands and thighs, abdominal cramping, labile mood, and intermittent psychosis. Plumbism was confirmed with sequentially elevated blood lead levels (BLLs). The patient opted for surgical removal of the bullet fragments, which led to reduction in BLLs and resolution of his symptoms. LESSONS Although rare, lead toxicity from retained intracranial bullet fragments should be considered in patients who have suffered a gunshot wound to the head and have symptoms of lead toxicity with elevated BLLs. For safe and accessible intracranial bullet fragments in patients with plumbism, surgical intervention may be indicated.
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Baum GR, Baum JT, Hayward D, MacKay BJ. Gunshot Wounds: Ballistics, Pathology, and Treatment Recommendations, with a Focus on Retained Bullets. Orthop Res Rev 2022; 14:293-317. [PMID: 36090309 PMCID: PMC9462949 DOI: 10.2147/orr.s378278] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 08/16/2022] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Gracie R Baum
- Department of Orthopedic Hand Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Jaxon T Baum
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Dan Hayward
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Brendan J MacKay
- Department of Orthopedic Hand Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA,Correspondence: Brendan J MacKay, Department of Orthopedic Hand Surgery, Texas Tech University Health Sciences Center, 808 Joliet Ave Suite 310, Lubbock, TX, 79415, USA, Tel +1 806 743 4600, Email
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14
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Survival following devastating penetrating gunshots polytrauma with grade 5 liver injuries requiring multiple massive transfusion protocols: A case report and review of the literature. Int J Surg Case Rep 2022; 98:107608. [PMCID: PMC9468388 DOI: 10.1016/j.ijscr.2022.107608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 08/31/2022] [Accepted: 09/03/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction A devastating injury to the liver from a gunshot wound (GSW) challenges the most seasoned trauma surgeon. This challenge is intensified when patients develop severe shock with a high-grade injury. We present the case of a patient with a grade 5 liver injury after a GSW treated with operative and interventional radiology (IR) treatment simultaneously. Case presentation A 25-year-old male presented to our Trauma Center with hypotension, after an abdominal GSW. He was taken emergently to the operating room, which revealed a Grade 5 liver injury with massive hemorrhage. Operative intervention was initiated immediately and a non-anatomic left lobectomy with hepatorrhaphy was performed. IR was consulted intra-operatively and performed a left hepatic artery angioembolization. The patient received over 50 units of blood products during the combined procedures, with eventual bleeding control. On post-operative day 33, the patient became acutely hemodynamically unstable, and angiography revealed a splenic artery pseudoaneurysm, which was embolized but re-bled and resulted in splenectomy. The patient eventually recovered and follows up at 1-year revealed a patient doing well. Discussion High-grade liver injuries carry significant mortality. Mortality worsens when severe shock is present. Operative intervention is the standard approach for patients who remain in shock. To help improve outcomes patients may benefit from a combined approach with the interventional radiology team. Conclusion The acute management of severe liver injuries when presenting with ongoing shock is beneficial to include both trauma surgeons with interventional radiologists. Further studies are needed to determine the best approach for this devastating injury. Severe hepatic injuries may require both operative management & angioembolization. Class 4 hemorrhagic shock often requires a massive transfusion protocol. Algorithms for operative/angiographic treatment of liver/spleen injuries are needed. Delayed hemorrhage after angioembolization for splenic pseudoaneurysm can occur.
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Fischer KR, Walton E, Jasani GN. United States' Infrastructure Bill Contains Hidden $15 Billion Investment in Violence Prevention: Lead Abatement. Front Public Health 2022; 10:885460. [PMID: 35874975 PMCID: PMC9301236 DOI: 10.3389/fpubh.2022.885460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/20/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Kyle R. Fischer
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
- *Correspondence: Kyle R. Fischer
| | - Erin Walton
- Department of Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, United States
| | - Gregory N. Jasani
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
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16
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Kani KK, Porrino JA, Chew FS. Low-velocity, civilian firearm extremity injuries-review and update for radiologists. Skeletal Radiol 2022; 51:1153-1171. [PMID: 34718857 DOI: 10.1007/s00256-021-03935-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/03/2021] [Accepted: 09/05/2021] [Indexed: 02/02/2023]
Abstract
Firearm injuries are a preventable epidemic in the USA. Extremities are commonly affected in gunshot injuries. Such injuries may be complex with concomitant osseous, soft tissue, and neurovascular components. The maximum wounding potential of a projectile is determined by its kinetic energy and the proportion of the kinetic energy that is transmitted to the target. Accurate assessment of ballistic injuries is dependent on utilizing the principles of wound ballistics, accurate bullet count, and ballistic trajectory analysis. The goals of this article are to review wound ballistics and the imaging evaluation of extremity civilian firearm injuries in the adult population, with emphasis on ballistic trajectory analysis, specific ballistic fracture patterns, and diffuse, secondary soft tissue ballistic injuries.
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Affiliation(s)
- Kimia Khalatbari Kani
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Jack A Porrino
- Yale Radiology and Biomedical Imaging, 330 Cedar Street, New Haven, CT, 06520-8042, USA
| | - Felix S Chew
- Department of Radiology, University of Washington, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA
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17
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Kravtsov MN, Manukovsky VA, Bulyshchenko GG, Mirzametov SD, Byvaltsev VA. Case Report: Full-Endoscopic Surgery for Bullet Wounds of the Spine: A Report of Three Cases. Front Surg 2022; 9:873365. [PMID: 35402482 PMCID: PMC8990913 DOI: 10.3389/fsurg.2022.873365] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/28/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives To determine the feasibility and evaluate effectiveness of full-endoscopic surgery in gunshot wound of the spine. Methods Three clinical cases of lumbar and thoracic spine bullet wounds made by firearms and traumatic weapons are described. Percutaneous endoscopic surgery was performed to extract bullet from the spinal canal. The results are compared to the data from literature. Results Percutaneous endoscopic approach to spinal canal with a possibility to extract a bullet, decompression of nerve roots, defect closure of the dura mater is demonstrated. Conclusion Good clinical outcomes allows to recommend percutaneous endoscopic surgery to manage similar lumbar and thoracic spine bullet wounds at the tertiary care level.
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Affiliation(s)
- Maxim N. Kravtsov
- Department of Neurosurgery, S.M. Kirov Military Medical Academy, St. Petersburg, Russia
- Saint-Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, Russia
- Department of Neurosurgery, North-Western State University n.a. I.I. Mechnikov, St. Petersburg, Russia
- *Correspondence: Maxim N. Kravtsov
| | - Vadim A. Manukovsky
- Saint-Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, Russia
- Department of Neurosurgery, North-Western State University n.a. I.I. Mechnikov, St. Petersburg, Russia
| | | | | | - Vadim A. Byvaltsev
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
- Department of Neurosurgery, Railway Clinical Hospital, Irkutsk, Russia
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18
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Yen JS, Yen TH. Lead poisoning induced by gunshot injury with retained bullet fragments. QJM 2022; 114:873-874. [PMID: 34014323 DOI: 10.1093/qjmed/hcab144] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- J-S Yen
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou 333, Taiwan
| | - T-H Yen
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou 333, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
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19
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Smith RN, Tracy BM, Smith S, Johnson S, Martin ND, Seamon MJ. Retained Bullets After Firearm Injury: A Survey on Surgeon Practice Patterns. JOURNAL OF INTERPERSONAL VIOLENCE 2022; 37:NP306-NP326. [PMID: 32370593 DOI: 10.1177/0886260520914557] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Randi N Smith
- Emory University School of Medicine, Atlanta, GA, USA
| | - Brett M Tracy
- Emory University School of Medicine, Atlanta, GA, USA
| | | | - Sean Johnson
- University of Pennsylvania, Philadelphia, PA, USA
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20
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Bullet fragment in the eustachian tube presenting as conductive hearing loss and lead toxicity. OTOLARYNGOLOGY CASE REPORTS 2021. [DOI: 10.1016/j.xocr.2021.100380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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21
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Skalny AV, Aschner M, Bobrovnitsky IP, Chen P, Tsatsakis A, Paoliello MMB, Buha Djordevic A, Tinkov AA. Environmental and health hazards of military metal pollution. ENVIRONMENTAL RESEARCH 2021; 201:111568. [PMID: 34174260 DOI: 10.1016/j.envres.2021.111568] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/18/2021] [Accepted: 06/18/2021] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Anatoly V Skalny
- IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; KG Razumovsky Moscow State University of Technologies and Management, Moscow, Russia
| | - Michael Aschner
- IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Igor P Bobrovnitsky
- IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; Centre for Strategic Planning of FMBA of Russia, Moscow, Russia
| | - Pan Chen
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aristidis Tsatsakis
- IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; Laboratory of Toxicology, Medical School, University of Crete, Voutes, Heraklion, Crete, Greece
| | - Monica M B Paoliello
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aleksandra Buha Djordevic
- Department of Toxicology "Akademik Danilo Soldatović", University of Belgrade - Faculty of Pharmacy, Belgrade, Serbia
| | - Alexey A Tinkov
- IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; Laboratory of Ecobiomonitoring and Quality Control, Yaroslavl State University, Yaroslavl, Russia.
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22
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Zhang X, Cain MD, Williams CD, Spears TA, Poulos CK. G2 Research Radically Invasive Projectile: The Importance of Recognizing Its Imaging and Autopsy Patterns. Am J Forensic Med Pathol 2021; 42:248-251. [PMID: 33560647 DOI: 10.1097/paf.0000000000000669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Many fragmenting and frangible projectiles have been developed in the course of firearm history. In addition, partially because of the concerns of range and environmental contamination, bullets constructed without lead have become increasingly common. A case regarding a unique projectile that incorporates both features, the G2 Research Radically Invasive Projectile ammunition, is discussed in this article. Here we report a 25-year-old woman who died of multiple gunshot wounds caused by G2 Research Radically Invasive Projectile ammunition. Because of the bullet's unique design, the wounds demonstrated characteristic radiographic patterns and unique autopsy findings. Familiarity with these findings is important to forensic pathologists in terms of case documentation, projectile recovery, and personal safety.
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Affiliation(s)
- Xin Zhang
- From the Department of Pathology, Indiana University
| | | | | | - Timothy A Spears
- Indianapolis-Marion County Forensic Services Agency, Indianapolis, IN
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23
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Nee N, Inaba K, Schellenberg M, Benjamin ER, Lam L, Matsushima K, Strumwasser AM, Demetriades D. Retained bullet fragments after nonfatal gunshot wounds: epidemiology and outcomes. J Trauma Acute Care Surg 2021; 90:973-979. [PMID: 33496545 DOI: 10.1097/ta.0000000000003089] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Nadya Nee
- From the Division of Trauma and Critical Care, LAC + USC Medical Center, Los Angeles, California
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24
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Khoshnamvand N, Azizi N, Hassanvand MS, Shamsipour M, Naddafi K, Oskoei V. Blood lead level monitoring related to environmental exposure in the general Iranian population: a systematic review and meta-analysis. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2021; 28:10.1007/s11356-021-14148-2. [PMID: 33948843 DOI: 10.1007/s11356-021-14148-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/22/2021] [Indexed: 06/12/2023]
Abstract
Exposure to lead can cause adverse health problems incorporating hypophosphatemia, heart and liver disease, cancers, neurological and cardiovascular diseases, central nervous disorders, and sensory disorders. This study investigated the blood lead level in the general Iranian population with environmental exposure to lead. In the presented systematic review and meta-analysis, the authors searched Iranian dataset, including Magiran, SID, Iranmedex, and Nopa, and the main dataset, comprising PubMed, Scopus, Embase, and Web of Science, all available articles until 12 January 2019, and extracting 55 studies (with 63 data for analysis) to a meta-analysis. A comprehensive meta-analysis software, pooled standard deviation, mean, sample size, and the utterly random effects model was analyzed in this study. The results showed that the overall mean BLL (95% CI) in total inquiries was 6.41 μg/dL (5.96 to 6.87). Besides, the results for gender and age subgroups were as follows: mean BLL, 6.47 μg/dL, 95% CI, 5.79, to 7.15, mean BLL, 6.44 μg/dL, 95% CI, 5.96, to 6.91, respectively. Conclusively the mean BLL in the Iranian population was higher than the recommended level by the US Centers for Disease Control and Prevention (CDC). Results indicated that the mean BLL in men and adults was more elevated than in women and children, respectively. Therefore, BLL monitoring and screening of the general Iranian population are is necessary to determine a reference value.
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Affiliation(s)
- Nahid Khoshnamvand
- Department of Environmental Health Engineering, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Nahid Azizi
- Department of Environmental Health Engineering, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Sadegh Hassanvand
- Center for Air Pollution Research, Institute for Environmental Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Mansour Shamsipour
- Department of Research Methodology and Data Analysis, Institute for Environmental Research (IER), Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Naddafi
- Department of Environmental Health Engineering, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
- Center for Air Pollution Research, Institute for Environmental Research, Tehran University of Medical Sciences, Tehran, Iran.
| | - Vahide Oskoei
- Department of Environmental Health Engineering, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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25
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Do lodged foreign bodies in the neck need to be removed? No defined criteria in 2020. Fluoroscopy role and review of literature: A case report. Trauma Case Rep 2020; 30:100362. [PMID: 33145389 PMCID: PMC7596329 DOI: 10.1016/j.tcr.2020.100362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2020] [Indexed: 11/22/2022] Open
Abstract
Penetrating neck wounds can be fatal and require prompt attention. The trauma literature is flooded with management protocols for penetrating wounds to the neck; however, in the absence of hard signs the definitive management of lodged foreign bodies beyond the platysma is less clear. This report describes a work-related injury of a Caucasian 33-year-old male who arrived in the Emergency Department (ER) with a 1 cm metallic foreign body (FB) lodged in zone II of the neck, 7 mm antero-lateral to the right internal carotid artery. The technical aspects of its retrieval are discussed as well as a literature review of the current management of embedded FBs in the neck. The patient was taken to the operating room and the FB was removed via a 3 cm incision. Fluoroscopy was used for exact localization of and to allow a precise skin incision overlying the FB. The FB was retrieved uneventfully; a fiberoptic esophagoscopy and bronchoscopy showed normal findings. The patient was discharged home the next day. At 15 months follow-up he is doing well without sequela. The use of fluoroscopy is strongly encouraged for FB removal in asymptomatic patients. The management of lodged foreign bodies in the neck should be part of future guidelines.
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26
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Özden R, Davut S, Doğramacı Y, Kalacı A, Duman İG, Uruç V. Treatment of secondary hip arthritis from shell fragment and gunshot injury in the Syrian civil war. J Orthop Surg Res 2020; 15:464. [PMID: 33032647 PMCID: PMC7545849 DOI: 10.1186/s13018-020-01993-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 10/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background In gunshot and shell fragment injuries to the hip joint, orthopedic intervention includes wound assessment and care, osteosynthesis of fractures, and avoiding of infection and osteoarthritis. Individuals injured in the Syrian civil war were frequently transferred to the authors’ institution in neighboring city. Orthopedic trauma exposures were determined in approximately 30% of these patients. The aim of this study was to evaluate the outcomes of the patients with secondary hip arthritis due to prior gunshot and shell fragment (shrapnel) injuries who underwent primary total hip arthroplasty. Methods This retrospective study reviewed 26 patients (24 males, 2 females) who underwent hip arthroplasty due to prior gunshot and shell fragment injuries from November 2013 to January 2019. For all patients, the Harris Hip Score (HHS) was evaluated preoperatively and after surgery. Results Mean age was 31.5 (range, 19–48) years. The mean preoperative HHS was 52.95 points, and the mean postoperative HHS was 79.92 points at the final follow-up after surgery. Patients with shell fragment injuries to the hip joint had higher infection rates, but it is not statistically significant. Conclusions An anatomic reduction of the fracture may not be possible in these cases as a result of significant bone and/or cartilage loss. Total hip arthroplasty can be done after gunshot- and shell fragment-related posttraumatic arthritis. It is an effective treatment choice to reduce pain and improve function, but the surgeon must be very careful because of high rate of infection.
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Affiliation(s)
- Raif Özden
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mustafa Kemal University, Serinyol, 31001, Antakya, Hatay, Turkey.
| | - Serkan Davut
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mustafa Kemal University, Serinyol, 31001, Antakya, Hatay, Turkey
| | - Yunus Doğramacı
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mustafa Kemal University, Serinyol, 31001, Antakya, Hatay, Turkey
| | - Aydıner Kalacı
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mustafa Kemal University, Serinyol, 31001, Antakya, Hatay, Turkey
| | - İbrahim Gökhan Duman
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mustafa Kemal University, Serinyol, 31001, Antakya, Hatay, Turkey
| | - Vedat Uruç
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mustafa Kemal University, Serinyol, 31001, Antakya, Hatay, Turkey
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27
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Gascho D. Lodged bullets on computed tomography: Three classification procedures for the virtual investigation of bullets or their fragments that cannot be recovered from the living patient. MEDICINE, SCIENCE, AND THE LAW 2020; 60:245-248. [PMID: 33054596 DOI: 10.1177/0025802420962697] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Dominic Gascho
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Switzerland
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28
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Gaitens JM, Potter BK, D'Alleyrand JG, Overmann AL, Gochfeld M, Smith DR, Breyer R, McDiarmid MA. 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. Am J Ind Med 2020; 63:381-393. [PMID: 32144801 DOI: 10.1002/ajim.23098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/10/2020] [Accepted: 02/21/2020] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Joanna M. Gaitens
- Department of Veterans Affairs Medical Center Baltimore and Department of MedicineUniversity of Maryland School of MedicineBaltimore Maryland
| | - Benjamin K. Potter
- Department of OrthopaedicsWalter Reed National Military Medical CenterBethesda Maryland
| | | | - Archie L. Overmann
- Department of OrthopaedicsWalter Reed National Military Medical CenterBethesda Maryland
| | - Michael Gochfeld
- Department of Environmental and Occupational Health, Environmental and Occupational Health Sciences InstituteRutgers Robert Wood Johnson Medical SchoolPiscataway New Jersey
| | - Donald R. Smith
- Department of Microbiology and Environmental ToxicologyUniversity of CaliforniaSanta Cruz California
| | - Richard Breyer
- Department of RadiologyBaltimore Veterans Affairs Medical CenterBaltimore Maryland
| | - Melissa A. McDiarmid
- Department of Veterans Affairs Medical Center Baltimore and Department of MedicineUniversity of Maryland School of MedicineBaltimore Maryland
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Are Patients With Retained Bullet Fragments at Greater Risk for Elevated Blood Lead Levels? Ann Emerg Med 2020; 75:365-367. [DOI: 10.1016/j.annemergmed.2019.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Indexed: 11/20/2022]
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