Written by Clay Smith
Patients with retained bullet fragments (RBF) are at risk for toxic lead levels and should probably be screened for the first year after ballistic injury.
Why does this matter?
Most of the time, it is not recommended to remove bullet fragments. This review noted the following exceptions: “joints, CSF, or the globe of the eye…impingement on a nerve or a nerve root, and bullets lying within the lumen of a vessel, resulting in a risk of ischemia or embolization, should be removed.” The CDC recommends lead levels in children be <5 μg/dL. Above this, children may have renal problems, hypertension, and adverse cognitive effects. In fact, there is no “safe” lead level, especially in children or pregnant women. Does leaving lead in other anatomic locations leach into the tissues and cause levels to rise?
Led by lead levels
This was a meta-analysis of 12 studies. They found that patients with retained bullet fragments (RBF) had elevated lead levels 5.47 μg/dL higher than controls; and the more RBF, the higher the level. Higher levels were also associated with bone fractures. The median lead level was 9 μg/dL. The authors recommend quarterly serial blood lead levels if RBF are present for a period of one year. If levels are rising, the RBF should be removed – assuming it can be done safely. This is a game-changer for me. I have always considered lead absorption to be so minimal as to obviate any concern. And for most, that’s still true. But for some, lead absorption may be unusually high. I plan to recommend patients with RBF follow up and have lead levels checked.
Lead toxicity from retained bullet fragments: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2019 Sep;87(3):707-716. doi: 10.1097/TA.0000000000002287.
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Reviewed by Thomas Davis