[Gunshot wounds: should projectiles and fragments always be removed?].
BACKGROUND
Projectiles or metal fragments can remain lodged in the body of victims of gunshot injuries. This also applies to projectiles which do not tend to deform or fragment on impact. When a projectile fragments on penetration, jacket or lead core particles are likely to remain lodged in the affected region even if the projectile has exited the body.


OBJECTIVE
A frequently asked question in the surgical management of such injuries is whether there are medical indications for the surgical removal of projectiles or fragments.


METHODS
This article presents some typical cases of patients who have received treatment at our institution and reviews the pertinent literature to show general recommendations in special cases concerning the removal of projectiles or fragments and when additional surgical trauma is justified. Parameters for decision making are presented in an algorithm.


RESULTS
From our own patients, 5 with remaining fragments in the soft tissue were invited for a clinical follow up. Serum probes and 24 h urine output was analysed for serum lead levels and urinary aminolevulinic acid levels. 74 months (max. 128 - min. 42 months) after injury we documented not elevated serum lead levels of 8.25 μg/ml and urinary aminolevulinic acid levels of 4.8 mg/24 h.


CONCLUSIONS
When lead-containing projectiles or fragments remain lodged in the body, monitoring is required and includes the measurement of serum lead levels and urinary aminolevulinic acid levels. The most important clinical symptoms of lead poisoning are gastrointestinal and neurological in nature. The treatment of choice for lead poisoning is the administration of chelating agents and removal of the lead source by surgical intervention.
Bundeswehrzentralkrankenhaus Koblenz, Rübenacher Str. 170, 56072, Koblenz, Deutschland, ErwinKollig@bundeswehr.org.
E
E
Kollig
S
S
Hentsch
A
A
Willms
D
D
Bieler
A
A
Franke
D000465:Algorithms; D000622:Aminolevulinic Acid / Q000652:urine; D003661:Decision Support Techniques; D005547:Foreign Bodies / Q000097:blood / Q000601:surgery*; D006801:Humans; D007854:Lead / Q000097:blood / Q000633:toxicity; D007855:Lead Poisoning / Q000175:diagnosis / Q000517:prevention & control; D008670:Metals / Q000633:toxicity; D008889:Military Personnel; D011183:Postoperative Complications / Q000097:blood; D014948:Wounds, Gunshot / Q000097:blood / Q000601:surgery*
D008670:Metals; D007854:Lead; D000622:Aminolevulinic Acid