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.
——Maria Alcocer, MD
Chicago
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.
| —— | John W. Harrington, MD Associate Professor of Pediatrics Eastern Virginia Medical School Norfolk, Va |