Retained bullets and lead toxicity: a systematic review

Area of Science:

• Toxicology
• Orthopedic Surgery
• Public Health

Background:

• Lead toxicity from retained bullets (RB) after gunshot wounds is a rare but underdiagnosed condition.
• Current management guidelines for surveillance, chelation, and surgical intervention are lacking.
• Firearm injuries are common in the United States, increasing the potential for RB-related lead exposure.

Approach:

• A comprehensive literature search was conducted using multiple databases (PubMed, EMBASE, Cochrane, CENTRAL).
• Keywords included "chelation," "lead poisoning," "lead toxicity," "lead," "bullet," "missile," and "gunshot."
• 1,082 articles were identified, with 142 included in the final review, primarily case reports.

Key Points:

• Risk factors for lead toxicity include RB location (especially intra-articular), fractures, trauma, fragment number, hypermetabolic states, and duration of retention.
• Symptoms of lead poisoning from RBs can be delayed, occurring months or years after the initial injury.
• Symptomatic patients with high blood lead levels (BLLs) often improve with chelation and surgical RB removal.

Conclusions:

• Serial BLL monitoring is suggested for patients with retained bullets.
• Early surgical removal of intra-articular RBs is warranted due to increased toxicity risk and vague symptoms.
• Multidisciplinary management is essential, and long-term chelation should not replace surgical intervention.