Get the Lead Out

Studies have shown that retained bullets are associated with higher rates of depression. Retained bullets are also associated with lead poisoning especially when the bullet is lodged in a bone. Despite this reality there is a lack of scholarship and consensus on the impact of retained bullets and their ongoing capacity for harm . Much to the surprise of the general public, it is standard practice to leave bullets inside patients if there is no emergent indication for surgery for an injured organ, broken bone, or internal bleeding.

The most definitive guidance based on metanalysis of 12 studies by Dr. Randi Smith:

“Patients with bony fractures or multiple RBF, who are at higher risk of elevated BLL, should be monitored for BLL in intervals of 3 months within the first year of injury. For patients who return with BLL above 5 μg/dL, all efforts must be undertaken to remove fragments if there is no potential to worsen the injury.”

At The BRIC we advocate for the following:

1 - Full disclosure to patients at the time of original assessment for BRI wounds to include information about number of injuries, depth of injuries, any possible fractures, and number and nature of retained bullets and fragments.

2 - Disclosure and review of radiographic images with immediate sharing of images with patients to allow for ongoing surveillance and aftercare of their retained bullets.

3 - Referral for early bullet removal (0-2 weeks after injury) for retained bullets at a depth of 1cm or less not associated any vital structures nor immediately adjacent fracture.

4 - Ongoing surveillance for emergence of bullets via ultrasound for any bullet at a depth of 3cm or less.

5 - Lead toxicity screening beginning at 6 months post injury for any retained with special attention to bullets retained within bone, spinal cord, brain, and any occurrence of multiple retained bullets.