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Tue Sep 2 03:36:35 BST 2008

I must disagree. While it is undoubtedly rare I think that lead toxicity from retained particulate lead does occur although, as noted previously, usually when it lies within some liquid or gelid area. While I am still living out of a suitcase and don't have access to my files, a quick search produces numerous case reports where lead toxicity was found and resolved after removal of the fragments. Granted, an elevated lead level in someone who lives in the less savory parts of our cities and happens to be carrying a bullet in their person is hardly conclusive, I think that a little time searching the literature will produce enough evidence to negate being able to say that it never occurs. A few samples:

Bolanos AA, Demizio JP Jr, Vigorita VJ, Bryk E. Lead poisoning from an intra-articular shotgun pellet in the knee treated with arthroscopic extraction and chelation therapy: a case report. J Bone Joint Surg. 1996;78 :422 –426

S. T. Mahan, M. M. Murray, A. D. Woolf, and J. R. Kasser
Increased Blood Lead Levels in an Adolescent Girl from a Retained Bullet. A Case Report J. Bone Joint Surg. Am., December 1, 2006; 88(12): 2726 – 2729

Farrell SE, Vandevander P, Schoffstall JM, Lee DC. Blood lead levels in emergency department patients with retained lead bullets and shrapnel. Acad Emerg Med. 1999;6 :208 –212

McQuirter JL, Rothenberg SJ, Dinkins GA, Kondrashov V, Manalo M, Todd AC. Change in blood lead concentration up to 1 year after a gunshot wound with a retained bullet. Am J Epidemiol. 2004;159 :683 –692

John BE, Boatright D. Lead toxicity from gunshot wound. South Med J. 1999;92 :223 –224

I know - they are all case reports and as such anecdotal but there are plenty more.

R Wigle MD FACS
LSU Shreveport

--- On Mon, 9/1/08, Robert F. Smith <rfsmithmd at comcast.net> wrote:

> From: Robert F. Smith <rfsmithmd at comcast.net>
> Subject: RE: question about projectile composition
> To: "'Trauma & Critical Care mailing list'" <trauma-list at trauma.org>
> Date: Monday, September 1, 2008, 5:47 PM
> I realize I'm really going out on a limb here, but I
> agree with Drs. Mattox
> and Stein. I trained in Occ Med back in the day and we
> tried to look for
> evidence of the effect of lead exposure through bullets.
> Sort of an overlap
> thing at Cook County Hospital. Everything was pretty
> equivocal at best.
> Sometimes you could find elevated serum Pb levels but the
> exposure to a
> variety of non-gunshot lead sources for patients from the
> South Side of
> Chicago was pretty high. But not necessarily uniform, you
> know. So it was
> hard to figure out to what we were or should be comparing
> the GSW victims
> to. I definitely don't ever remember a pt. with
> "poisoning" from a bullet.
> The worst possible scenario I could imagine would have been
> a lead bullet
> left exactly in the spinal canal. And how often would that
> happen??
> 
> Rob Smith
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of KMATTOX at aol.com
> Sent: Monday, September 01, 2008 4:51 PM
> To: trauma-list at trauma.org
> Subject: Re: question about projectile composition
> 
> Mickey's skepticism regarding "lead or metal"
> poisoning from metal  
> projectiles is several quantum less than mine.     I have 
> read some
> laboratory issues 
> regarding this subject, but have never seen either  in
> street fighters, war 
> wounds, referred patients, or any others any problems  that
> I was smart
> enough 
> to identify.    I was taught and  continue to leave
> missiles stay where they
> 
> are, unless they have caused bleeding  problems.      I am
> aware of the 
> literature that real  LEAD bullets exposed to a synovial
> joint can result in
> lead 
> absorption, but have  never seen any good evidence for
> such.      Many of
> the  
> projectiles we see are really not LEAD.    I do believe
> that  there is a
> great 
> deal of urban legend here and a great deal of old wives
> tales  and retold 
> culture which either needs to be killed or have some
> science behind  it.
> 
>  
> But what do I know after being involved in and or
> supervising more than  
> 70,000 injured patients during my clinical career as a
> medical student,
> resident, 
> soldier, and faculty since 1960.     
>  
> k
>  
>  
> In a message dated 9/1/2008 3:39:32 P.M. Central Daylight
> Time,  
> mgstein at bezeqint.net writes:
> 
> Hello  all,
> 
> 
> 
> I am a bit perplexed!!
> 
> 
> 
> I began Med School  in 1972.  Served as a Medic (1973) and
> Doctor
> (1982,1991,2006) in four  wars. Seen thousands of war
> casualties and
> personally treated hundreds of  shrapnel/projectile victims
> of explosives
> and
> firearms.  Treated  hundreds of suicide bombing victims
> (and have data on
> some 8000 others from  other med. centers around the
> country) from all sorts
> of stuff that the  terrorists' twisted minds try to add
> to the explosives.
> 
> 
> 
> In all  these years (1973-2008) I have never never never
> seen a metal
> substance  poisoning from these projectiles.  Oh, we did
> see these particles
> to  cause severe problems.  However, all were mechanical or
>  infectious
> complications.  Those (infectious complications) were seen 
> more commonly
> with the non-metalic projectiles or if traversed through 
> contaminated
> organs
> (i.e. hollow viscus etc.).  More so, I have never  heard of
> anyone who saw
> these types of complications (including the 2 years  I
> spent at STC in
> Baltimore MD 1993-5).
> 
> 
> 
> Personal experience  is Level 6 :-) or less evidence but.
> 
> 
> 
> Am I blind?
> 
> Am I  deaf?
> 
> Is it such a scarce issue?
> 
> Are my patients just  LUCKY?
> 
> Do they use different "Metals" in the Middle
> East?
> 
> Are we  divinely protected from this type of complication
> in the
> "Holy-Land"?
> 
> Is the King Naked?
> 
> All or some of the  above?
> 
> 
> 
> Your humble devils  advocate.
> 
> 
> 
> Mickey
> 
> 
> 
> *******************************************************************
> 
> Michael  Stein MD
> 
> Chairman, Israel Trauma Society
> 
> Director of Trauma,  Attending Surgeon
> 
> Department of Surgery,
> 
> Rabin Medical Center -  Beilinson Hospital,
> 
> Petach-Tikva,  49100
> 
> ISRAEL
> 
> ******************************************************************
> 
> 
> 
> 
> 
> -----Original  Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of listasmsd
> Sent:  Monday, September 01, 2008 1:28 PM
> To: Trauma &amp; Critical Care  mailing list
> Subject: Re: question about projectile  composition
> 
> 
> 
> old data
> 
> Am J Forensic Med Pathol. 1983  Jun;4(2):165-9. Links
> 
> A fatal case of lead poisoning due to a retained  bullet.
> 
> DiMaio VJ, DiMaio SM, Garriott JC, Simpson P.
> 
> Lead  poisoning from a retained bullet or missile is rare
> and is usually  
> 
> dependent on the location of the missile in a bone or
> immediately  adjacent 
> 
> to a joint. A review of the literature revealed only 14
> cases  in which
> there
> 
> 
> was adequate laboratory documentation of plumbism  caused
> by a retained 
> 
> bullet or missile. Only one of these previously  reported
> cases resulted in 
> 
> death. We report a second death due to lead  poisoning from
> a retained
> bullet
> 
> 
> with elevated blood lead levels  documented by toxicologic
> analysis.>
> 
> > 
> 
> > 
> 
> >  Hello again all, In the news today I saw that the
> army is studying  the
> 
> > longterm effects of shrapnel left in the bodies of
> soldiers.  It made me
> 
> > think of all the GSW fragments I have seen left in 
> patients over the
> 
> > years. The standard missile composition I  understand
> to be copper
> jacketed
> 
> > lead. Also common hollow point  and softpoint
> projectiles have no covering
> 
> > at all. Does anyone  know of the longterm health
> effects of tihs either in
> 
> > civillian  studies or anecdotes? What about
> projectiles with tungsten?
> Does
> 
> >  location in the body have an effect on outcome? Look
> forward to the
> input
> 
> > from the list. thanks again,Mike
> 
> > 
> 
> >  
> 
> > 
> 
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question about projectile composition