Gunshot Victims With Embedded Fragments: Check for Leaching Lead

Dr John Harrington's Photoclinic case of a young girl who sustained a gunshot wound in a drive-by shooting (Gunshot Wound) highlighted a very important topic. Unfortunately, I have had many similar cases. I would urge-in this patient and in others who have embedded metal fragments-that clinicians do routine lead level measurements and blood work to check for anemia. An embedded bullet can leach lead into the bloodstream, resulting in a significantly elevated lead level.

For further information on how best to monitor such patients for chronic lead exposure, I suggest contacting the local public health department.

I appreciate your insightful comments, and although my case write-up was necessarily brief, I regret that I did not cover that important aspect of managing gunshot wounds, especially in the vulnerable population of juvenile shooting victims.

The radiograph showed that our patient had just 1 very tiny embedded fragment/lead-based pellet from the snakeshot shell-and that the fragment was not near a joint, bone, or vessel, which means that she would be considered low risk. Thus, we were not immediately too concerned about lead toxicity.

However, after reviewing the literature¹ and speaking with our institution's lead expert, we concluded that it would be prudent to follow up with a serum lead level measurement, 6 to 12 months after the injury. Because we do screen for lead in high-risk zip codes in our area, our patient had had her lead level measured at age 4: it was less than 3 μg/dL. Thus, we at least know that she had no lead toxicity before the incident.

References:

REFERENCE:

1.

McQuirter JL, Rothenberg SJ, Dinkins GA, et al. Change in blood lead concentration up to 1 year after a gunshot wound with a retained bullet.

Am J Epidemiol

. 2004;159:683-692.