Trends in firearm injury in a southern California health care system from 2010 to 2020.

BACKGROUND: Firearm injury is a significant public health concern in the United States. METHODS: Data on fatal and nonfatal firearm injuries were obtained from a cohort of N = 7,473,650 members of Kaiser Permanente Southern California, a large integrated healthcare system between 2010 and 2020. Age-adjusted rates of combined fatal and nonfatal firearm injury per 100,000 members were calculated by year, with the 2010 US census as the reference population. Trends were evaluated using Poisson or negative binomial regression. RESULTS: There was an increasing trend in overall firearm injuries between 2010 and 2020 among adults in this large integrated healthcare system (p < .0001), primarily driven by non-self-inflicted firearm injuries (p < .0001). Self-inflicted injuries decreased during this time (p = .01). Injuries among youth showed no significant change. CONCLUSION: There was an increasing trend in firearm injuries between 2010 and 2020 among adults in this large integrated healthcare system, primarily driven by non-self-inflicted firearm injuries; however, self-inflicted injuries decreased during this time. Injuries among youth showed no significant change.

Spiritual coping behaviors among injured urban black men in Philadelphia.

PURPOSE: High rates of firearm injury among urban Black men in the US can lead to long physical and psychological recovery times, worsened by limited access to mental health services. Spirituality can propel positive thoughts, actions, perceptions and behaviors about self and others yet how it is used among Black men recovering from firearm injury is underexplored. This study examined the role of spirituality in the recovery of Black male survivors of firearm injury. METHOD: Ten injured urban Black men in Philadelphia were interviewed using descriptive phenomenology. A subset of participants from the Emotional Responses and Recovery from Injury in Urban Black Men study who agreed to be recontacted for future studies were enrolled. Informed consent was obtained, semi-structured interviews were conducted via phone and were audiotaped, transcribed, and de-identified. Thematic content analysis was used to understand perceptions of spirituality and to identify spiritual coping behavior themes. RESULTS: Findings suggest that injured urban Black men engaged in theistic and non-theistic spiritual activities that resulted in positive character development, reduced risk of re-injury, hope, improved mental health and social bonds. CONCLUSION: Spirituality may serve as a protective factor against firearm re-injury or retaliation by promoting desired behaviors and mental health among injured urban Black men. Combining culturally sensitive spiritual resources and psychotherapy may lead to effective trauma-informed care in addressing spiritual and existential challenges of injured urban Black men who may find spirituality important.

Retrospective analysis of 261 autopsies of penetrating cardiac injuries with emphasis on sociodemographic factors.

Penetrating cardiac injuries (PCIs) are highly lethal and several factors are related to its incidence and mortality. While most studies focus on characterizing patients who arrived at a medical facility alive and exploring the relationship between the degree of heart compromise and mortality, our study delved deeper into the topic. This study analyzed 261 autopsy reports from 2017 in Bogotá, Colombia, and characterized the factors surrounding PCI incidence and mortality while emphasizing the role of sociodemographic variables. Of these cases, 247 (94.6%) were males with a mean age of 29.19 ± 9.7 years. Weekends, holidays, and late hours had the highest incidence of PCIs. The victims' deaths occurred at the scene in 66 (25.3%) cases, and 65.1% of the victims died before receiving medical care. Upon admission, patients with vital signs were more likely to have been transported by taxi or a private vehicle. Two or more compromised cardiac chambers, increased time of transportation, trauma occurred in the city outskirts, and gunshot wounds were related to increased mortality. Our data is valuable for surgeons, health system managers, and policy analysts as we conducted a holistic assessment of the anatomical and sociodemographic factors that are closely associated with mortality following a PCI. Surgeons must recognize that PCIs can occur even when the entrance wound is outside the cardiac box. Reinforcing hospital infrastructure in the outskirts and improving the availability, accuracy, and response time of first responders may lead to improved patient mortality rates.

Factors Associated With Firearm Injury Among Pediatric Members of a Large Integrated Healthcare System.

BACKGROUND AND OBJECTIVES: Few studies have tested multiple socio-ecological risk factors assocated with firearm injury among pediatric populations and distinguished self-inflicted from non-self-inflicted injury. To address this gap, the current study examined demographic, individual psychosocial, and neighborhood variables as risk factors for firearm injury among a large cohort of children and adolescents. METHODS: Retrospective cohort study. Data were obtained from the electronic health records of a large integrated healthcare system. The cohort included children <18 years with at least one clinical encounter between January 1, 2010 and December 31, 2018. Poisson regression was used to examine demographic (age, gender, race and ethnicity, Medicaid status), psychosocial (depression, substance use disorder, medical comorbidities), and neighborhood education variables as potential risk factors for non-self-inflicted and self-inflicted firearm injuries. RESULTS: For non-self-inflicted injury, the highest relative risk was found for children age 12-17 years old compared to 0-5 year olds (RR = 37.57); other risk factors included male gender, Black and Hispanic race and ethnicity (compared to White race), being a Medicaid recipient, lower neighborhood education, and substance use disorder diagnosis. For self-inflicted injury, only age 12-17 years old and male gender were associated with increased risk. CONCLUSIONS: These results reinforce the established higher risk for firearm injury among adolescent males, highlight differences between self-inflicted and non-self-inflicted injuries, and the need to consider demographic, psychosocial, and neighborhood variables as risk factors to inform interventions aimed to reduce firearm injuries among children and adolescents.

Observational study of early diaphragm pacing in cervical spinal cord injured patients to decrease mechanical ventilation during the COVID-19 pandemic.

BACKGROUND: Decreasing the burden of mechanical ventilation for spinal cord injuries was never more relevant than during the COVID-19 pandemic. Data have shown diaphragm pacing can replace mechanical ventilation, decrease wean times, improve respiratory mechanics, and decrease hospital costs for patients with spinal cord injuries. This is the largest report of diaphragm pacing during the pandemic. METHODS: This is a retrospective analysis of prospective Institutional Review Board approved databases of nonrandomized interventional experience at a single institution. Subgroup analysis limited to traumatic cervical spinal cord injuries that were implanted laparoscopically with diaphragm electrodes within 30 days of injury. RESULTS: For the study group of early implanted traumatic cervical spinal cord injuries, 13 subjects were identified from a database of 197 diaphragm pacing implantations from January 1, 2020, to December 31, 2022, for all indications. All subjects were male with an average age of 49.3 years (range, 17-70). Injury mechanisms included falls (6), motor vehicle accident (4), gunshot wound (2), and diving (1). Time from injury to diaphragm pacing averaged 11 days (range, 3-22). Two patients are deceased and neither weaned from mechanical ventilation. Nine of the remaining 11 patients weaned from mechanical ventilation. Four patients never had a tracheostomy and 3 additional patients had tracheostomy decannulation. Three of these high-risk pulmonary compromised patients survived COVID-19 infections utilizing diaphragm pacing. CONCLUSION: Diaphragm pacing successfully weaned from mechanical ventilation 82% of patients surviving past 90 days. Forty-four percent of this group never underwent a tracheostomy. Only 22% of the weaned group required long term tracheostomies. Early diaphragm pacing for spinal cord injuries decreases mechanical ventilation usage and tracheostomy need which allows for earlier placement for rehabilitation.

Presença de risco de transtorno do estresse pós-traumático em policiais militares feridos por arma de fogo / Presence of risk of posttraumatic stress disorder in military police officers wounded by firearms / Presencia de riesgo de trastorno de estrés postraumático en policías militares heridos por armamiento de fuego

Este estudo teve como objetivo identificar o risco de desenvolvimento de transtorno de estresse pós-traumático (TEPT), bem como sua associação com pensamentos ou tentativas suicidas e a saúde mental de policiais militares feridos por arma de fogo, na Região Metropolitana de Belém (RMB), nos anos de 2017 a 2019. A pesquisa contou com a participação de 30 entrevistados, que responderam o Inventário Demográfico e a Lista de verificação de TEPT para o DSM-5 (PCL-5). Para análise dos dados, utilizou-se a técnica estatística Análise Exploratória de Dados e a técnica multivariada Análise de Correspondência. Os resultados revelaram a existência de risco de desenvolvimento do transtorno de forma parcial ou total em uma expressiva parcela da população entrevistada, tendo homens como maioria dos sintomáticos, com média de 38 anos, exercendo atividades operacionais e vitimados em via pública quando estavam de folga do serviço. O ferimento deixou a maioria com sequelas, com destaque para dores crônicas, limitações de locomoção e/ou mobilidade e perda parcial de um membro. E, ainda, policiais sintomáticos apresentaram comportamentos suicidas, relatando já terem pensado ou tentado tirar a própria vida. Desta forma, conclui-se que policiais militares são expostos constantemente a traumas inerentes a sua profissão. Quando há ameaça de vida, como nos casos de ferimentos por arma de fogo, são suscetíveis a sequelas físicas decorrente do ferimento, somadas a sequelas mentais tardias, como o surgimento de sintomatologias de TEPT e ideação suicida.(AU)

This study aimed to identify the risk of developing post-traumatic stress disorder (PTSD) and its associations around suicidal thoughts or attempts and mental health in military police officers injured by firearms, in the Metropolitan Region of Belem (RMB), from 2017 to 2019. The research had the participation of 30 respondents who answered the Demographic Inventory and the PTSD checklist for DSM-5 (PCL-5). For data analysis, we used the statistical technique Exploratory Data Analysis and the multivariate technique Correspondence Analysis. The results revealed the existence of risk of developing partial or total disorder in a significant portion of the interviewed population, with men as most of the symptomatic individuals, with mean age of 38 years, developing operational activities and victimized on public roads when they were off duty. The injuries left most of them with sequelae, especially chronic pain, limited locomotion and/or mobility, and partial loss of a limb. In addition, symptomatic officers showed suicidal behavior, such as reporting they had thought about or tried to take their own lives. Thus, we conclude that military policemen are constantly exposed to traumas inherent to their profession. When their lives are threatened, as in the case of firearm wounds, they are susceptible to physical sequelae resulting from the injury, in addition to late mental sequelae, such as the appearance of PTSD symptoms and suicidal ideation.(AU)

Este estudio tuvo como objetivo identificar el riesgo de desarrollo de trastorno de estrés postraumático (TEPT) y sus asociaciones con pensamientos o tentativas suicidas y la salud mental en policías militares heridos por armamiento de fuego, en la Región Metropolitana de Belém (Brasil), en el período entre 2017 y 2019. En el estudio participaron 30 entrevistados que respondieron el Inventario Demográfico y la Lista de verificación de TEPT para el DSM-5 (PCL-5). Para el análisis de datos se utilizaron la técnica estadística Análisis Exploratoria de Datos y la técnica multivariada Análisis de Correspondencia. Los resultados revelaron que existen riesgos de desarrollo de trastorno de estrés postraumático de forma parcial o total en una expresiva parcela de la población de policías entrevistados, cuya mayoría de sintomáticos eran hombres, de 38 años en media, que ejercen actividades operacionales y fueron victimados en vía pública cuándo estaban de día libre del servicio. La lesión dejó la mayoría con secuelas, especialmente con dolores crónicos, limitaciones de locomoción y/o movilidad y la pierda parcial de un miembro. Aún los policías sintomáticos presentaran comportamiento suicida, tales como relataran qué ya pensaron o tentaron quitar la propia vida. Se concluye que los policías militaran se exponen constantemente a los traumas inherentes a su profesión. Cuando existe amenaza de vida, como en los casos de heridas por armamiento de fuego, son expuestos a secuelas físicas transcurridas de la herida, sumado a secuelas mentales tardías, como el surgimiento de sintomatologías de TEPT y la ideación suicida.(AU)

A preliminary study on the treatment of human blood soiled stubs, in presence of GSR particles.

In the investigation of gunshot deaths, Bloodstains Pattern Analysis (BPA) and, in particular, backspatter patterns found on the body of the suspect/victim and on the surfaces close to the entrance wound of the bullet can provide investigators with important indications on the dynamics of the events. Backspatter patterns have, however, morphological characteristics common to other bloodstains of different origin, so, in order to positively identify them, a possible solution is represented by their sampling, using an aluminum stub for electron microscopy, for the detection of gunshot residues (GSR) present. The latter, however, if present below the small blood crusts, could be difficult to detect during analysis by Scanning Electron Microscopy/Energy Dispersive X-ray microanalysis (SEM/EDX). In this preliminary study we propose the treatment of the stub surface with a solution based on sodium hypochlorite and calcium chloride, in order to remove/reduce the blood crusts present on the stub surface.

A systematic review of clinical and laboratory findings of lead poisoning: lessons from case reports.

Lead is one of the most toxic heavy metals in the environment. The present review aimed to highlight hazardous pollution sources, management, and review symptoms of lead poisonings in various parts of the world. The present study summarized the information available from case reports and case series studies from 2009 to March 2020 on the lead pollution sources and clinical symptoms. All are along with detoxification methods in infants, children, and adults. Our literature compilation includes results from 126 studies on lead poisoning. We found that traditional medication, occupational exposure, and substance abuse are as common as previously reported sources of lead exposure for children and adults. Ayurvedic medications and gunshot wounds have been identified as the most common source of exposure in the United States. However, opium and occupational exposure to the batteries were primarily seen in Iran and India. Furthermore, neurological, gastrointestinal, and hematological disorders were the most frequently occurring symptoms in lead-poisoned patients. As for therapeutic strategies, our findings confirm the safety and efficacy of chelating agents, even for infants. Our results suggest that treatment with chelating agents combined with the prevention of environmental exposure may be an excellent strategy to reduce the rate of lead poisoning. Besides, more clinical studies and long-term follow-ups are necessary to address all questions about lead poisoning management.

Pleiotropic actions of Vitamin D in composite musculoskeletal trauma.

Composite tissue injuries are the result of high energy impacts caused by motor vehicle accidents, gunshot wounds or blasts. These are highly traumatic injuries characterized by wide-spread, penetrating wounds affecting the entire musculoskeletal system, and are generally defined by frank volumetric muscle loss with concomitant segmental bone defects. At the tissue level, the breadth of damage to multiple tissue systems, and potential for infection from penetration, have been shown to lead to an exaggerated, often chronic inflammatory response with subsequent dysregulation of normal musculoskeletal healing mechanisms. Aside from the direct effects of inflammation on myogenesis and osteogenesis, frank muscle loss has been shown to directly impair fracture union and ultimately contribute to failed wound regeneration. Care for these injuries requires extensive surgical intervention and acute care strategies. However, often these interventions do not adequately mitigate inflammation or promote proper musculoskeletal injury repair and force amputation of the limb. Therefore, identification of factors that can promote tissue regeneration and mitigate inflammation could be key to restoring wound healing after composite tissue injury. One such factor that may directly affect both inflammation and tissue regeneration in response to these multi-tissue injuries may be Vitamin D. Beyond traditional roles, the pleiotropic and localized actions of Vitamin D are increasingly being recognized in most aspects of wound healing in complex tissue injuries - e.g., regulation of inflammation, myogenesis, fracture callus mineralization and remodeling. Conversely, pre-existing Vitamin D deficiency leads to musculoskeletal dysfunction, increased fracture risk or fracture non-unions, decreased strength/function and reduced capacity to heal wounds through increased inflammation. This Vitamin D deficient state requires acute supplementation in order to quickly restore circulating levels to an optimal level, thereby facilitating a robust wound healing response. Herein, the purpose of this review is to address the roles and critical functions of Vitamin D throughout the wound healing process. Findings from this review suggest that careful monitoring and/or supplementation of Vitamin D may be critical for wound regeneration in composite tissue injuries.

Lead Toxicity From Intradiscal Retained Bullet Fragment: Management Considerations and Recommendations.

BACKGROUND: Lead toxicity (plumbism) secondary to retained lead missiles in synovial joint spaces is a rare complication after gunshot injuries. Management of lead missiles in the intradiscal space regarding potential lead toxicity is less certain. CASE DESCRIPTION: We reviewed the literature regarding lead toxicity secondary to intradiscal bullets particularly concerning incidence, management, and outcomes. A lack of high-quality published data precludes a meta-analysis from taking place. Only four reports of lead toxicity secondary to missiles in the intradiscal space have been published. Including an additional case presented in this report, our review of the literature has led us to make several management recommendations, largely based on both the available literature and our current report. CONCLUSIONS: First, there is insufficient evidence for removing retained lead missiles solely to mitigate the risk of lead toxicity. Second, chelation therapy in addition to surgical removal of the lead source is a valuable adjunct in the perioperative period and should be undertaken with the assistance of medical toxicology. Third, a retained missile does not mandate a simultaneous stabilization procedure in lieu of other indications based on the data available at this time.

Partnering With Patients to Reduce Firearm-Related Death and Injury.

In the United States, nearly 40,000 deaths per year are firearm related. Among these fatalities are approximately 1300 children. In addition, there are more than 20,000 unintentional firearm injuries per year. Osteopathic physicians have a unique opportunity to affect this public health concern through patient education. Several evidenced-based recommendations can be incorporated at the bedside to reduce firearm injuries and deaths, including gun education, safe storage, and proper disposal.

[Antimicrobial anti-inflammatory photodynamic and light-emitting-diode phototherapy of the consequences of the gunshot and mine-blast injury to the face, head, and neck including damage to the ENT organs]. / Antimikrobnaia protivovospalitel'naia fotodinamicheskaia i svetodiodnaia fototerapiia posledstvii ognestrel'noi i minno-vzryvnoi travmy golovy i shei.

The objective of the present study was the enhancement of the effectiveness of the treatment of the consequences of the gunshot wounds and mine-blast injuries inflicted to the face, head, and neck encountered in the otolaryngological practice as well as the prevention of the formation of the large demarcation areas in the injured tissues and the preparation of these tissues for the further restorative treatment. Anti-microbial and anti-inflammatory photodynamic therapy (PDT) as well as light-emitting-diode (LED) phototherapy were carried out in 20 patients who suffered gunshot wounds and mine-blast injuries to the face, head, and neck. The photodynamic therapy was performed with the use of an aqueous solution of methylene blue at a concentration of 0.1%, the 'Alod-1' infrared laser ('Granat' modification, Russia), and the 'AFS-Solaris' light-emitting diode-based phototherapeutic apparatus (Russia). The analysis of the results of the study has demonstrated the high efficiency of the proposed approach that made it possible to prevent the development of severe septic complications, reduce the amount of drug therapy, significantly shorten duration of the treatment, and create the conditions for the earlier rehabilitation and further plastic and cosmetic restoration of the tissue structures.

Index Use of Smoflipid in a Tertiary Intestinal Rehabilitation and Transplantation Program.

Long-term parenteral nutrition (PN) may be complicated by PN-associated liver disease (PNALD), and some studies suggest an association between the use of soy-based fat emulsions and PNALD development. Patients' liver function typically improves and PNALD resolves after reducing or stopping a soy-based fat emulsion, and thus lipid minimization has been the primary strategy for managing PNALD in many intestinal rehabilitation programs. However, fat emulsions often cannot be stopped entirely, leading some patients to develop PNALD even after lipid reduction strategies have been implemented. Smoflipid emulsion (Kabi-Fresenius, Bad Homburg, Germany), a balanced mixture of soybean oil, medium-chain triglycerides (MCTs), olive oil, and fish oil, was recently approved by the Food and Drug Administration for use in the United States as an equivalent alternative to Intralipid (Baxter Healthcare Corporation, Deerfield, IL). In several pediatric studies, patients who received Smoflipid had significantly lower serum bilirubin levels than those who received Intralipid. In this case report, we present a patient who developed severe PNALD with subsequent resolution after 20 weeks on Smoflipid.

Severe Systemic Lead Toxicity Resulting From Extra-Articular Retained Shrapnel Presenting as Jaundice and Hepatitis: A Case Report and Review of the Literature.

INTRODUCTION: Despite greater than 60,000 nonfatal firearm injuries per year in the United States, retained shrapnel is a relatively rare cause of systemic lead toxicity with less than 100 cases reported in the medical literature since 1867. While intra-articular retained shrapnel as a cause of lead toxicity is well-described, extra-articular fragments are less well known to cause symptomatic disease. CASE REPORT: A 31-year-old man initially presented with abdominal pain, constipation, jaundice, and elevated liver transaminases approximately 3 weeks after suffering a left lower extremity injury during athletic activity. The patient was found to have steatohepatitis after extensive inpatient and outpatient gastroenterological workup to include upper and lower endoscopy, liver ultrasound, and biopsy of the liver to confirm the diagnosis. Imaging was incidentally notable for retained gunshot in the left flank and large shell fragment containing seroma in the left thigh. The patient was initially discharged with improved pain, but later presented to a primary care clinic with weight loss and continued pain. This was followed by a subsequent progression to diffuse weakness, ultimately resulting in an inability to ambulate. The patient was readmitted to a tertiary care medical center, 3 months after the initial presentation. Physical exam was then notable for 70-lb weight loss from initial admission and diffuse peripheral weakness with global muscle atrophy. Following a broad differential workup, he was found to have a blood lead level of 129 µg/dL, and hemoglobin of 7.7 g/dL with basophilic stippling on peripheral smear. The patient was transferred to the intensive care unit for chelation therapy with dimercaprol and calcium ethylenediaminetetraacetic acid. Lead levels initially decreased, but rose when patient was transitioned to oral therapy with succimer. Surgery was consulted for removal of multiple retained fragments, which were analyzed by the Joint Pathology Center and found to contain lead. The patient's motor function gradually improved on oral chelation and he was discharged to a subacute rehabilitation facility. CONCLUSION: This complex case describes a rare cause for a relatively common clinical presentation, jaundice and hepatitis, and reinforces the importance of longitudinal follow up and reassessment of a patient with an unknown illness and worsening clinical condition. Diagnosis of systemic lead toxicity is challenging because of its protean clinical manifestations, and relative rarity with the advent of strict environmental lead controls and decrease in lead-based paint and industrial products. Furthermore, extra-articular lead remains a rare cause of systemic toxicity, and the surgical standard of care has been to not remove these fragments in gunshot victims. This case adds to a small amount of evidence that lead screening may be of value in selected patients with extra-articular retained shrapnel, especially those with seroma and osteophyte formation in the wound.

Imaging mass spectrometry of elements in forensic cases by LA-ICP-MS.

Laser ablation inductively coupled plasma mass spectrometry (LA-ICP-MS) was performed to map elements in thin formalin-fixed paraffin-embedded tissue sections of two forensic cases with firearm and electrocution injuries, respectively. In both cases, histological examination of the wounded tissue regions revealed the presence of exogenous aggregates that may be interpreted as metallic depositions. The use of imaging LA-ICP-MS allowed us to unambiguously determine the elemental composition of the observed aggregates assisting the pathologist in case assessments. To the best of our knowledge, we demonstrate for the first time the use of imaging LA-ICP-MS as a complementary tool for forensic pathologists and toxicologists in order to map the presence of metals and other elements in thin tissue sections of post-mortem cases.

Quadriparesis Caused by Lead Poisoning Nine Years After a Gunshot Wound With Retained Bullet Fragments: A Case Report.

Lead toxicity in adults is characterized by nonspecific symptoms of abdominal pain, vomiting, constipation, fatigue, and weight loss. We present a case of severe lead toxicity that developed subacutely, causing quadriparesis 9 years after a gunshot wound with retained bullet fragments. The onset of symptoms may have been related to the development of a pseudocyst. The long interval between the gunshot wound and the onset of symptoms contributed to a delay in suspecting that the retained bullet was a source of lead toxicity. The patient's symptoms gradually improved after chelation therapy, removal of the bullet fragment, and an extended program of acute inpatient rehabilitation. LEVEL OF EVIDENCE: V.

Consider Autotransfusion in the Field.

Massive hemothorax is a life-threatening condition that can present as hemorrhagic shock, cardiogenic shock, or elements of both. It is described by the American College of Surgeons, in the 9th Edition of Advanced Trauma Life Support, as a rapid accumulation of more than 1,500 mL of blood or one-third or more of the patient's blood volume. The use of autotransfusion systems has been implemented for the treatment of hemothorax in hospital settings. The implementation of autotransfusion has been documented in situations where an extended period can elapse before definitive treatment can occur. This article is the first described case where an autotransfusion system has been implemented in a prehospital setting, at a Role 1 medical facility, for massive hemothorax in Afghanistan.

Retained Lumbar Bullet: A Case Report of Chronic Lead Toxicity and Review of the Literature.

BACKGROUND: Lead toxicity from retained bullet fragments is difficult to both predict and diagnose, but important to treat early, given the potential severity of disease. Blood lead levels > 25 µg/dL and 40 µg/dL are considered toxic in children and adults, respectively. Symptoms may range from nonspecific constitutional symptoms to seizures and coma. Chelation is the mainstay therapy for lead poisoning and levels to treat depend on patient age, blood lead levels, and the presence of symptoms. CASE  REPORT: We present the case of a woman with symptoms of severe lead toxicity from 20-year-old retained bullet fragments. She had been seen by multiple providers for evaluation of each symptom, but a unifying diagnosis had not been found. After identifying this complication, she was treated appropriately and more serious complications were prevented. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of lead toxicity in patients with a seemingly unrelated constellation of symptoms and a history of a previous gunshot wound with retained bullet or bullet fragments.

Nausea, Vomiting, and Weight Loss in a Young Adult Patient With a History of a Gunshot Wound.

Assessing victims of gunshot wounds with retained bullets/bullet fragments for lead toxicity is not always considered until the patient develops signs and symptoms of toxicity. We discuss the case of a 19-year-old young man who received a diagnosis of chronic lead toxicity (serum lead concentration 51 µg/dL) 5 weeks after a hunting accident. Extensive wound debridement occurred following the accident; however, lead toxicity was not diagnosed until after his fourth emergency department visit. Oral chelation therapy was required for the management of his lead toxicity.