All posts by The Trauma Pro

Complications

Can Lead Poisoning Occur After A Gunshot?

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This is a fairly common question from victims of gunshots and their families. As you know, bullets are routinely left in place unless they are superficial. It may cause more damage to try to extract one, especially if it has come to rest in a deep location. But is there danger in leaving the bullet alone?

One of the classic papers on this topic was published in 1982 by Erwin Thal at Parkland Hospital in Dallas. The paper recounted a series of 16 patients who had developed signs and symptoms of lead poisoning (plumbism) after a gunshot or shotgun injury. The common thread in these cases was that the injury involved a joint or bursa near a joint. In some cases the missile passed through the joint/bursa but came to rest nearby, and a synovial pseudocyst formed which included the piece of lead. The joint fluid bathing the projectile caused lead to leach into the circulation.

The patients in the Parkland paper developed symptoms anywhere from 3 days to 40 years after injury. As is the case with plumbism, symptoms were variable and nonspecific. Patients presented with abdominal pain, anemia, cognitive problems, renal dysfunction and seizures to name a few.

Bottom line: Any patient with a bullet or lead shot that is located in or near a joint or bursa should have the missile(s) promptly and surgically removed. Any lead that has come to rest within the GI tract (particularly the stomach) must be removed as well. If a patient presents with odd symptoms and has a history of a retained bullet, obtain a toxicology consult and begin a workup for lead poisoning. If levels are elevated, the missile must be extracted. Chelation therapy should be started preop because manipulation of the site may further increase lead levels. The missile and any stained tissues or pseudocyst must be removed in their entirety.

Granted, this is a very old paper. Over the years, a few papers on the topic have popped up from time to time. In my next post, I’ll review a meta-analysis on this topic that was published just last year.

Reference: Lead poisoning from retained bullets. Ann Surg 195(3):305-313, 1982.

Head, Technology

AI Can Detect Emergence From Coma Better Than Doctors

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Recovery from severe traumatic brain injury (TBI) can be frustrating for families and trauma professionals alike. It occurs in fits and starts, and the longest wait occurs while waiting for the patient to wake up. We perform serial neurologic exams and monitor closely for any visible response to commands.

A group of medical and engineering researchers at SUNY Stony Brook theorized that muscle movements in response to commands might be too subtle for human detection during early emergence from coma. They developed an AI system called SeeMe that studied the patients’ facial appearance down to the level of pores, and trained it to detect very fine motor movements in response to three commands:

  • Stick out your tongue
  • Open your eyes
  • Show me a smile

A group of 16 normal volunteers and 37 TBI patients were then tested while being video recorded. Both SeeMe and trained experts judged responses.

Here are the factoids:

  • SeeMe detected facial responses 4 days earlier than the trained experts
  • It detected eye opening in 86% vs 74% of human observers
  • SeeMe was able to detect mouth movements in 94% of patients without endotracheal tubes
  • The SeeMe-detected responses correlated with the clinical outcome at discharge

Bottom line: Severely brain-injured patients are able to respond to commands with subtle facial muscle movements before human observers can detect them. A specially trained AI like SeeMe can identify these movements and help predict recovery sooner than clinicians. Imagine being able to tell the family, who has been seeing their loved one making no progress, that improvement is occurring! And imagine what other applications focused AI can have on other clinical areas where human senses don’t have the capacity that carefully trained machines do!

Reference: Computer vision detects covert voluntary facial movements in unresponsive brain injury patients. Commun Med 5, 361 (2025). https://doi.org/10.1038/s43856-025-01042-y

General

Gunshot To The Face!

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You’ve just been pre-notified of an incoming trauma activation: gunshot to the face. No other information. How concerned should you be? Here are some things to think about as you wait for the patient to arrive:

  • Is it really a gunshot? Sometimes shotgun injuries are reported as gunshots. Big difference!
  • Will I need to preserve evidence? In general, yes. In most cases other than suicide attempts, there is probably a good chance that criminal activity was involved. Be prepared to preserve all patient belongings in paper bags, and have a chain of custody form available.
  • Am I and my team safe? There is a possibility that someone wants your incoming patient dead. They may want to finish the job, in you emergency department. Make sure the area is secure.

Once the patient arrives, it’s best to think through things via the ATLS framework.

  • Airway. If the injury involves the lower part of the face or neck, make sure the airway is safe and/or secure. Blood may create problems, as can edema from injury to soft tissues, especially in the floor of the mouth.
  • Breathing. Not a problem with these injuries unless significant aspiration has occurred.
  • Circulation. The face can really bleed, and only a few areas are amenable to the usual surgical control (clamping, tying). Direct pressure must be used for the rest, and this doesn’t always work. Bleeding from sinuses may be controlled with packing or the foley catheter trick (inserted through bullet tract). But if you can’t stop it, then it’s time to expedite to the OR.
  • Disability. You do have to worry about the cervical spine if the path of the bullet is not obvious. If the patient is stable, immobilize the neck and use the CT scanner to see if any fragments involved the spine. If you must run to the OR with an unstable patient, then try to quickly shoot an old-fashioned cross-table lateral. This will give you quick and dirty info on how much you can manipulate the neck.

Related posts:

Mechanism

Closing Velocity And Injury Severity

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Trauma professionals, both prehospital and in trauma centers, make a big deal about “closing velocity” when describing motor vehicle crashes.  How important is this?

So let me give you a little quiz to illustrate the concept:

Two cars, of the same make and model, are both traveling on a two lane highway at 60 mph in opposite directions. Car A crosses the midline and strikes Car B head-on. This is the same as:

  1. Car A striking a wall at 120 mph
  2. Car B striking a wall at 60 mph
  3. Car A striking a wall at 30 mph

2010-saab-9-5-head-on-crash-test_100313384_m1

The closing velocity is calculated by adding the head-on components of both vehicles. Since the cars struck each other exactly head-on, this would be 60+60 = 120 mph. If the impact is angled there is a little trigonometry involved, which I will avoid in this example. And if there is a large difference in mass between the vehicles, there are some other calculation nuances as well.

So a closing velocity of 120 mph means that the injuries are worse than what you would expect from a car traveling at 60 mph, right?

Wrong!

In this example, since the masses are the same, each vehicle would come to a stop on impact because the masses are equal. This is equivalent to each vehicle striking a solid wall and decelerating from 60 mph to zero immediately. Hence, answer #2 is correct. If you remember your physics, momentum must be conserved, so both of these cars can’t have struck each other at the equivalent of 120 mph. The injuries sustained by any passengers will be those expected in a 60 mph crash.

If you change the scenario a little so that a car and a freight train are traveling toward each other at 60 mph each, the closing velocity is still 120 mph. However, due the the fact that the car’s mass is negligible compared to the train, it will strike the train, decelerate to 0, then accelerate to -60 mph in mere moments. The train will not slow down a bit. For occupants of the car, this would be equivalent to striking an immovable wall at 120 mph. The injuries will probably be immediately fatal for all.

Bottom line: Closing velocity has little relationship to the injuries sustained for most passenger vehicle crashes. The sum of the decelerations of the two vehicles will always equal the closing velocity. Those injuries will be consistent with the change in speed of the vehicle the occupants were riding, and not the sum of the velocities of the vehicles. 

Trauma Center

Virtual Site Visit Walkthrough Best Practice

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The American College of Surgeons Committee on Trauma and many state systems have adopted a virtual site review process since the pandemic. There are pros and cons to this choice, but one of the most significant issues that is difficult to surmount is the physical plan walkthrough. It is typically done using one or more cameras connected to teleconferencing software, which tours various trauma-related areas in the hospital.

Unfortunately, this approach leaves the reviewers with an incomplete appreciation of the hospital layout. When it comes to moving trauma patients from the ambulance unloading area to various treatment areas, the mental picture the reviewers draw from the separate cameras doesn’t do justice to your hospital’s physical plant. It’s like trying to interpret a CT scan made of only six slices.

What can be done to remedy this? The easiest solution is to provide a map that the reviewers can refer to in advance. It should show the locations of the key areas that trauma patients visit (ED, CT, OR, ICU, blood bank) with the approximate distances listed. This simple tool will make the reviewers’ lives (and yours) much easier if you provide it in advance. They can then visualize the logistics at your center more easily.

Here is a sample map to give you an idea of how it might look. Just click the image to see a larger view.

Bottom line: To assist in the review process, provide a map of key areas of the virtual walkthrough. It should display those areas, and if not readily apparent, spell out the approximate distance from one to the other. There is usually no place to add this to the application, so you may need to send it to your reviewers separately.

Click here for my virtual video walkthrough best practices document