- Discussion:
- bullets in soft tissue are rapidily encapsulated by fibrous tissue and are therefore essentially eliminated from circulating body fluids;
- where as serum is a poor solvent and bullets that are in joints are more threatening because of their contact with synovial fluid
combined with joint motion, will increase the rate of dissolution;
- synovial fluid is acidic which also increases its absorption;
- also be aware of absorption possibilities with lead within a bursa pseudocyst, lung tissue, bone, and suppurating foci;
- once plumbism is diagnosed, surgery is not the first line of treatment;
- anemia is one of the many signs of lead toxicity;
- patient should be stabilized and then receive
D-penicillamine to keep serum lead levels below 80 mg/dL;
- this prevents fatal mobilization of lead during surgery;
- in the report by Joseph L. McQuirter et al, the authors attempted to assess the impact of retained projectiles on
subsequent lead exposure in the population;
- 48 patients were originally recruited from gunshot victims presenting for care at the King/Drew Medical Center in Los Angeles, California;
- an initial blood level was measured for all recruited patients and repeated for the 28 participants available for follow-up, 1 week to 8 months later;
- medical history, including a history of prior firearm injuries and other retained projectiles, was taken, along with a screening and risk factor questionnaire
to determine other sources of lead (occupational/recreational) to which the patient might have been, or is at present, exposed;
- the participants also had K-shell x-ray fluorescence determinations of bone lead in the tibia and calcaneus in order to determine past lead exposures
not revealed by medical history and risk factor questionnaire;
- multivariate models of blood level were made using risk factor and bone lead concentration data;
- the authors demonstrated that blood lead tends to increase with time after injury in patients with projectile retention,
and that the increase in significant part depended on the presence of a bone fracture caused by the gunshot;
- the authors suggested that the amount of blood lead increase in time after injury is also dependent on the tibia lead concentration;
- there were too few cases in the study to fully test the effects of bullet location, or the interaction of bullet location with bone fracture or bullet fragmentation;
The Effects of Retained Lead Bullets on Body Lead Burden
Joseph L. McQuirter, DDS; Journal of Trauma 2001;50:892-899
