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>        We recently had a 10 year old boy in our department who hadswallowed
>one of his Dads bullets(38 caliber I believe). As the bullet was in the
>stomach our main concern was potential for leakage of the contents.   A
>quick review of the literature and local discussion didn't reveal any
>information on the subject. Anybody have experience or thoughts?
 
 
There are case reports of lead toxicity resulting from bullet fragments
that have been present in tissue for a period of time, usually months to
years (1,2,3).  Most commonly this occurs when the fragments are adjacent
to bone or in the pleural space.  I'm not sure if gastric acid provides a
good medium for dissolution of lead, or not, but there is at least one
case report of a bullet traversing the GI track uneventfully (4).
 
I assume that this was not a miltary style fully jacketed bullet in which
case, I would presume, the likelihood of leakage must be very low.
 
 
H. Louzon MD
 
 
(1)
 
 
Meggs WJ, Gerr F, Aly MH, Kierena T, Roberts DL, Shih R, Kim HC, Hoffman R
The treatment of lead poisoning from gunshot wounds with succimer (DMSA)
[see comments]
J Toxicol Clin Toxicol 1994;32(4):377-85
 
Lead poisoning is an unusual complication of gunshot wounds that occurs when
retained lead bullet fragments are in contact with body fluids capable of
solubilizing lead. The epidemic of violence by gunfire may result in
increasing numbers of lead poisoning cases from this exposure. The use of
oral chelation for toxicity resulting from this mode of exposure has not
been previously discussed. Cases of lead poisoning arising from bullet lead
in the synovial cavity of the hip, synovial cavity of the chest, and pleural
space are reported. A combination of surgical debridement and chelation
therapy with oral succimer produced a satisfactory outcome in all three
cases. Oral succimer may be a safe and effective chelation agent for
treating lead toxicity in adults with high lead levels secondary to gun
shot wounds.
 
(2)
 
 
Dillman RO, Crumb CK, Lidsky MJ
Lead poisoning from a gunshot wound. Report of a case and review of the
literature.
Am J Med 1979 Mar;66(3):509-14
 
A man was hospitalized on three occasions for symptoms of lead intoxication
20 to 25 years after a gunshot wound that resulted in retention of a lead
bullet in his hip joint. The potential for lead toxicity as a complication
of a lead missile injury appears to be related to (1) the surface area of
lead exposed for dissolution, (2) the location of the lead projectile, and
(3) the length of time during which body tissues are exposed to absorbable
lead. Cases of lead poisoning of immediate onset resulting from lead shot
have been reported in Europe, but all documented cases of ammunition-related
plumbism reported in the United States have involved synovial fluid
dissolution of a single lead bullet over many years. The solvent
characteristics of synovial fluid and associated local arthritis are
apparently important factors in the dissolution and absorption of lead from
projectiles located in joints. Awareness that lead intoxication can be a
complication of retained lead projectiles should allow rapid institution of
appropriate diagnostic and therapeutic modalities when such a clinical
situation arises.
 
 
(3)
 
 
DiMaio VJ, DiMaio SM, Garriott JC, Simpson P
A fatal case of lead poisoning due to a retained bullet.
Am J Forensic Med Pathol 1983 Jun;4(2):165-9
 
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.
 
 
(4)
 
 
Morrow JS, Haycock CE, Lazaro E
The "swallowed bullet" syndrome.
J Trauma 1978 Jun;18(6):464-6
 
A unique case is reported in which a bullet, after entering the maxillary
antrum, penetrated the hard palate, was deflected into the esophagus where
it struck the cervical spine, and then passed uneventfully through the
gastrointestinal tract.
 
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