Original Article

Characteristics of Pediatric Patients With Retained Bullet Fragments and Need for Follow-Up Blood Lead Monitoring

Authors: Todd Fleenor, MD, Joshua Haupt, MD, Kathleen Richard, MD, Michele Nichols, MD, Nipam Shah, MBBS, MPH


Objectives: Multiple case reports of lead toxicity related to retained bullet fragments in pediatric patients sustaining gunshot wound have been published. The purpose of the present study was to determine whether the demographic and clinical characteristics of gunshot wounds (GSWs) could be classified high/low risk and whether routine blood lead monitoring is necessary in these patients.

Methods: A single-center prospective case series of pediatric GSW patients presenting to the emergency department (ED). The data points that were collected and analyzed included age, sex, race, wound location, disposition, and baseline and follow-up lead levels within 6 months post-injury.

Results: Twenty patients were enrolled in the study and the median age was 7.5 years (interquartile range 5.25–10.75); 75% of the patients were African American. A total of 15 patients (75%) had injuries in either a lower or upper extremity, 9 of whom required admission. Almost all of the injuries involving the head, chest, or abdomen required admission. Of the patients, 65% were admitted and 35% were discharged. All of the patients had an initial blood lead level taken, and follow-up lead levels were determined at 6 months post-injury to be <5 μg/dL. Twelve of 20 patients were lost to follow-up.

Conclusions: Pediatric GSW is common in male African Americans and these patients had baseline and follow-up lead levels below the reference level. These patients were difficult to follow up. Based on the available data, follow-up lead monitoring may not be indicated.
Posted in: Emergency & Disaster Medicine11

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1. Fowler KA, Dahlberg LL, Haileyesus T, et al. Childhood firearm injuries in the United States. Pediatrics 2017;140:e20163486.
2. Leventhal JM, Gaither JR, Sege R. Hospitalizations due to firearm injuries in children and adolescents. Pediatrics 2014;133:219-225.
3. Newgard CD, Kuppermann N, Holmes JF, et al. Gunshot injuries in children served by emergency services. Pediatrics 2013;132:862-870.
4. Teitelbaum GP, Yee CA, Van Horn DD, et al. Metallic ballistic fragments: MR imaging safety and artifacts. Radiology 1990;175:855-859.
5. de Araujo GCS, Mourao NT, Pinheiro IN, et al. Lead toxicity risks in gunshot victims. PLoS One 2015;10:e0140220.
6. American Academy of Pediatrics Committee on Environmental Health. Lead exposure in children: prevention, detection, and management. Pediatrics 2005;116:1036-1046.
7. Bellinger DC. Lead. Pediatrics 2004;113(4 suppl):1016-1022.
8. Centers for Disease Control and Prevention. Managing Elevated Blood Lead Levels Among Young Children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention. www.cdc.gov/nceh/lead/casemanagement/casemanage_main.htm. Published March 2002. Accessed August 13, 2019.
9. Jusko TA, Henderson CR, Jr Lanphear BP, et al. Blood lead concentrations < 10 μ/dL and child intelligence at 6 years of age. Environ Health Perspect 2008;116:243-248.
10. Canfield RL, Henderson CR, Jr Cory-Slechta DA, et al. Intellectual impairment in children with blood lead concentrations below 10 μ per deciliter. N Engl J Med 2003;348:1517-1526.
11. Centers for Disease Control and Prevention. Preventing lead poisoning in young children. https://www.cdc.gov/nceh/lead/publications/PrevLeadPoisoning.pdf. Published 2005. Accessed October 20, 2019.
12. Mazumdar M, Bellinger DC, Gregas M, et al. Low-level environmental lead exposure in childhood and adult intellectual function: a follow-up study. Environ Health 2011;10:24.
13. Lanphear BP, Hornung R, Khoury J, et al. Low-level environmental lead exposure and children's intellectual function: an international pooled analysis. Environ Health Perspect 2005;113:894-899.
14. Chisolm JJ, Jr. Chronic lead intoxication in children. Dev Med Child Neurol 1965;7:529-536.
15. Chisolm JJ, Jr Harrison HE. The treatment of acute lead encephalopathy in children. Pediatrics 1957;19:2-20.
16. James J, Fitzgibbon J, Blackford M. Nausea, vomiting, and weight loss in a young adult patient with a history of a gunshot wound. Pediatr Emerg Care 2016;32:616-618.
17. Mahan ST, Murray MM, Woolf AD, et al. Increased blood lead levels in an adolescent girl from a retained bullet. A case report. J Bone Joint Surg Am 2006;88:2726-2729.
18. Coon T, Miller M, Shirazi F, et al. Lead toxicity in a 14-year-old female with retained bullet fragments. Pediatrics 2006;117:227-230.
19. Kikano GE, Stange KC. Lead poisoning in a child after a gunshot injury. J Fam Pract 1992;34:498-504.
20. Selbst SM, Henretig F, Fee MA, et al. Lead poisoning in a child with a gunshot wound. Pediatrics 1986;77:413-416.
21. Meggs WJ, Gerr F, Aly MH, et al. The treatment of lead poisoning from gunshot wounds with succimer (DMSA). J Toxicol Clin Toxicol 1994;32:377-385.
22. McQuirter JL, Rothenberg SJ, Dinkins GA, et al. Change in blood lead concentration up to 1 year after a gunshot wound with a retained bullet. Am J Epidemiol 2004;159:683-692.
23. Nickel WN, Steelman TJ, Sabath ZR, et al. Extra-articular retained missiles is surveillance of lead levels needed? Mil Med 2018;183:e107-e113.
24. Centers for Disease Control and Prevention. Blood lead levels in children. https://www.cdc.gov/nceh/lead/acclpp/blood_lead_levels.htm. Accessed June 6, 2018.
25. Centers for Disease Control and Prevention. Preventing Lead Poisoning in Young Children: Chapter 2. https://wonder.cdc.gov/wonder/prevguid/p0000029/p0000029.asp#head007000000000000. Accessed October 20, 2019.
26. Senger C, Keijzer R, Smith G, et al. Pediatric firearm injuries: a 10-year single-center experience of 194 patients. J Pediatr Surg 2011;46:927-932.
27. Choi PM, Hong C, Bansal S, et al. Firearm injuries in the pediatric population: a tale of one city. J Trauma Acute Care Surg 2016;80:64-69.
28. Martin CA, Unni P, Landman MP, et al. Race disparities in firearm injuries and outcomes among Tennessee children. J Pediatr Surg 2012;47:1196-1203.
29. Moazeni M, Alibeigi MF, Sayadi M, et al. The serum lead level in patients with retained lead pellets. Arch Trauma Res 2014;3:e18950.
30. Weiss D, Tomasallo CD, Meiman JG, et al. Elevated blood lead levels associated with retained bullet fragments-United States, 2003-2012. MMWR Morb Mortal Wkly Rep 2017;66:130-133.
31. Branson RD, Davis K, Jr Butler KL. African Americans' participation in clinical research: importance, barriers, and solutions. Am J Surg 2007;193:32-40.
32. Luebbert R, Perez A. Barriers to clinical research participation among African Americans. J Transcult Nurs 2016;27:456-463.
33. Coakley M, Fadiran EO, Parrish LJ, et al. Dialogues on diversifying clinical trials: successful strategies for engaging women and minorities in clinical trials. J Womens Health (Larchmt) 2012;21:713-716.
34. Kennedy BR, Mathis CC, Woods AK. African Americans and their distrust of the health care system: healthcare for diverse populations. J Cult Divers 2007;14:56-60.
35. Harris Y, Gorelick PB, Samuels P, et al. Why African Americans may not be participating in clinical trials. J Natl Med Assoc 1996;88:630-634.
36. Gorelick PB, Harris Y, Burnett B, et al. The recruitment triangle: reasons why African Americans enroll, refuse to enroll, or voluntarily withdraw from a clinical trial. An interim report from the African-American Antiplatelet Stroke Prevention Study (AAASPS). J Natl Med Assoc 1998;90:141-145.
37. Shavers-Hornaday VL, Lynch CF, Burmeister LF, et al. Why are African Americans under-represented in medical research studies? Impediments to participation. Ethn Health 1997;2:31-45.