1. Quail, Myles Thomas MS Ed, RN, LNC

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I recently learned that bullet removal is not routinely indicated for victims of gunshot injuries with retained bullet fragments unless they are a cause of immediate morbidity. Are these patients at risk for lead toxicity?-H.B., N.J.


Myles Thomas Quail, MS Ed, RN, LNC, responds: Based on the composition and location of a retained bullet or bullet fragment (projectiles), removal may not be necessary in all patients.1-3 The medical literature has reported less than 100 cases of lead toxicity since the mid-1800s. Although lead poisoning is possible, it's not likely.4,5 Elevated blood lead levels (BLL) in these circumstances have been linked to advanced age; the presence of a fracture, especially near a joint; and a higher number of retained fragments.1,3


Not all patients with retained projectiles become symptomatic, nor can clinicians predict whether a patient will develop lead toxicity from a retained projectile. For example, projectiles retained in soft tissue are usually considered low-risk because they often become encapsulated and isolated.1,2,6 They should be removed if they begin to surface, become painful or infected, or create systemic toxicity.1,2,6,7


When many projectiles are present, removal may be indicated because the projectiles can solubilize and cause systemic toxicity. Metals and metal mixtures under development for new munitions are not tested for potential adverse health reactions.8,9


If a patient has multiple projectiles, especially near a bone fracture, these should be removed due to the risk of delayed healing, nonunion, or cartilage degradation.2 In addition, projectiles should be surgically removed when they are lodged in any intra-articular location, the palms of the hands, or the soles of the feet.2,6,7 Surgical removal is also indicated when the projectile is immersed in cerebrospinal or synovial fluid. Projectiles, especially those that contain lead, can leach and cause systemic absorption and elevated BLL when subjected to these fluids.2,3,6,7


Adults with chronic low-level lead exposure due to retained projectiles may present with vague, nonspecific symptoms or be completely asymptomatic. Symptoms may include abdominal cramping, altered mental status, anemia, anorexia, diarrhea, fatigue, headache, hypertension, irritability, insomnia, myalgia, nausea, vomiting, weakness, and weight loss.1,10


Asymptomatic adults with prolonged lower levels of lead could still develop long-term adverse reactions involving the cardiovascular, cognitive, renal, and other organ systems.10 Before discharge, all patients with retained projectiles require a baseline BLL, radiographic images, and a urine sample for heavy metals.1,8,9 Accurate and detailed medical records documenting the projectile's location will be pertinent if the patient returns later with symptoms. Military personnel and veterans should provide a 24-hour urine collection specimen for heavy metals, uranium, and other organic materials.3,7-9 They should also be enrolled in the VA Embedded Fragments Registry.8,9,11 This registry was established in 2009 to identify and monitor all military personnel and veterans who have had projectiles, either still embedded or previously removed, to determine if any health effects exist and to develop appropriate treatment plans.8,9




1. Bustamante ND, Macias-Konstantopoulos WL. Retained lumbar bullet: a case report of chronic lead toxicity and review of the literature. J Emerg Med. 2016;51(1):45-49. [Context Link]


2. Riehl JT, Sassoon A, Connolly K, Haidukewych GJ, Koval KJ. Retained bullet removal in civilian pelvis and extremity gunshot injuries: a systematic review. Clin Orthop Relat Res. 2013;471(12):3956-3960. [Context Link]


3. 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(5):130-133. [Context Link]


4. 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(3):208-212. [Context Link]


5. 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(7):683-692. [Context Link]


6. Grasso IA, Blattner MR, Short T, Downs JW. Severe systemic lead toxicity resulting from extra-articular retained shrapnel presenting as jaundice and hepatitis: a case report and review of the literature. Mil Med. 2017;182(3):e1843-e1848. [Context Link]


7. Eward WC, Darcey D, Dodd LG, Zura RD. Case report: lead toxicity associated with an extra-articular retained missile 14 years after injury. J Surg Orthop Adv. 2011;20(4):241-246. [Context Link]


8. Kalinich JF, Vane EA, Centeno JA, et al Chapter 4: Embedded metal fragments. In: Annual Review of Nursing Research: Military Interventions. New York, NY: Springer Publishing Company; 2014:63-78. [Context Link]


9. Gaitens JM, McDiarmid MA. Airborne Hazards Related to Deployment, Book 52. Fort Sam Houston, TX: Borden Institute; 2015:245-252. [Context Link]


10. Goldman RH, Hu H. Adult lead poisoning. UpToDate. 2016. [Context Link]


11. US Department of Veterans Affairs, Office of Public Health. Toxic Embedded Fragment Surveillance Center. [Context Link]