Elevated Blood Lead Levels Associated with Retained Bullet Fragments - United States, 2003-2012.

An estimated 115,000 firearm injuries occur annually in the United States, and approximately 70% are nonfatal (1). Retained bullet fragments (RBFs) are an infrequently reported, but important, cause of lead toxicity; symptoms are often nonspecific and can appear years after suffering a gunshot wound (2,3). Adult blood lead level (BLL) screening is most commonly indicated for monitoring of occupational lead exposure; routine testing of adults with RBFs is infrequent (3). States collaborate with CDC's National Institute for Occupational Safety and Health (NIOSH) to monitor elevated BLLs through the Adult Blood Lead Epidemiology and Surveillance (ABLES) program (4,5). To help assess the public health burden of RBFs, data for persons with BLLs ≥10 µg/dL reported to ABLES during 2003-2012 were analyzed. An RBF-associated case was defined as a BLL ≥10 µg/dL in a person with an RBF. A non-RBF-associated case was defined as a BLL ≥10 µg/dL without an RBF. During 2003-2012, a total of 145,811 persons aged ≥16 years with BLLs ≥10 µg/dL were reported to ABLES in 41 states. Among these, 457 RBF-associated cases were identified with a maximum RBF-associated BLL of 306 µg/dL. RBF-associated cases accounted for 0.3% of all BLLs ≥10 µg/dL and 4.9% of BLLs ≥80 µg/dL. Elevated BLLs associated with RBFs occurred primarily among young adult males in nonoccupational settings. Low levels of suspicion of lead toxicity from RBFs by medical providers might cause a delay in diagnosis (3). Health care providers should inquire about an RBF as the potential cause for lead toxicity in an adult with an elevated BLL whose lead exposure is undetermined.

Low-risk criteria for pelvic radiography in pediatric blunt trauma patients.

CONTEXT: The American College of Surgeons recommends that any patient with blunt trauma undergoes radiographic evaluation, including a radiograph of the pelvis. Studies have questioned the use of such routine pelvic radiographs (PXR) in pediatrics. Selective elimination of PXR would save time, money and unshielded radiation exposure to the gonads. OBJECTIVE: To determine if a defined set of historical and clinical factors could predict low risk for pelvic fracture and incorporate these factors into a clinical decision guideline. DESIGN, SETTING, AND PATIENTS: A retrospective chart review of all blunt trauma patients 25 years or younger in whom a PXR was obtained from January 2002 to June 2006 presenting to an urban level 1 trauma center. A total of 579 patients underwent 580 trauma evaluations. MAIN OUTCOME MEASURES: Variables including sex, mechanism of injury, Glascow Coma Score, Pediatric Trauma Score, fall height, lower extremity injury, blood on rectal examination, blood at meatus, and clinical need for computed tomography (CT) were compared with outcomes of pelvic fracture and pelvic fracture requiring surgical intervention. RESULTS: There were 22 pelvic fractures identified, resulting in a fracture rate of 4%. The negative predictive value for pelvic fracture was 98.3% (95% confidence interval [95% CI], 96.9%-99.2%) if no lower extremity injury was present, 99% (95% CI, 98.2%-99.6%) if physical examination of the pelvis was normal, and 99.5% (95% CI, 98.6%-99.9%) if there was no need for abdominopelvic CT. The negative predictive value was 100% (95% CI, 98.8%-100%) if any one of these 3 factors is present. CONCLUSIONS: Using the clinical findings of (1) lack of lower extremity injury, (2) lack of an abnormal physical examination of the pelvis, and (3) no need for abdominopelvic CT, pelvic fracture can be reliably excluded. Pelvic radiography can be eliminated in the evaluation of these patients, potentially decreasing time expenditure, radiation exposure, and cost.

Multisystem organ failure after large volume injection of castor oil.

We report a case of multisystem organ failure after large volume subcutaneous injection of castor oil for cosmetic enhancement. An unlicensed practitioner injected 500 mL of castor oil bilaterally to the hips and buttocks of a 28-year-old male to female transsexual. Immediate local pain and erythema were followed by abdominal and chest pain, emesis, headache, hematuria, jaundice, and tinnitus. She presented to an emergency department 12 hours postinjection. Persistently hemolyzed blood samples complicated preliminary laboratory analysis. She rapidly deteriorated despite treatment and developed fever, tachycardia, hemolysis, thrombocytopenia, hepatitis, respiratory distress, and anuric renal failure. An infectious diseases evaluation was negative. After intensive supportive care, including mechanical ventilation and hemodialysis, she was discharged 11 days later, requiring dialysis for an additional 1.5 months. Castor oil absorption was inferred from recovery of the Ricinus communis biomarker, ricinine, in the patient's urine (41 ng/mL). Clinicians should anticipate multiple complications after unapproved methods of cosmetic enhancement.