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Retained bullets and lead toxicity: a systematic review.

Emily K Kershner^1,2, Natasha Tobarran^1,2, Andrew Chambers^1,2

¹Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA.

Clinical Toxicology (Philadelphia, Pa.)

|September 8, 2022

Summary

Lead toxicity from retained bullets (RB) is underdiagnosed. Early surgical removal of intra-articular RBs is recommended for patients with lead poisoning, alongside serial blood lead level monitoring.

Keywords:

Lead toxicity chelation retained bullets retained lead systematic review

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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.