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Gun Shot Wounds: Plumbism

- 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