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Iron Ingestion

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Iron Ingestion, Iron Poisoning, Acute Iron Toxicity, Acute Iron Poisoning

  • Precautions
  1. Iron toxicity after acute ingestion is difficult to gauge
  2. Iron supplements in overdosage may be lethal in children (FDA black box warning)
  • Pathophysiology
  • Iron Toxicity
  1. Stage 1: Gastrointestinal (0.5 to 6 hours)
    1. Abdominal Pain
    2. Nausea and Vomiting
    3. Diarrhea
    4. Hematemesis
    5. Melana
    6. Lethargy
  2. Stage 2: Latent Period (6 to 24 hours)
    1. Metabolic Acidosis may be present
    2. Lethargy may be present
    3. Hypotension may be present
  3. Stage 3: Systemic Toxicity and Shock (4 to 40 hours)
    1. Cyanosis
    2. Hypovolemia and Hypotension (shock)
    3. Lactic Acidosis
    4. Lethargy
    5. Restlessness
    6. Disorientation to Coma
    7. Convulsions
    8. Coagulopathy
  4. Stage 4: Late Complications (>40 hours)
    1. Hepatotoxicity (onset within 48 hours)
    2. Gastric outlet obstruction or Small Bowel Obstruction (2-8 weeks)
  • Labs
  1. See Overdose
  2. Serum Iron levels predict severity of ingestion
  • Management
  1. ABC Management
  2. Contact poison control
  3. Initial emergent supportive care for shock
    1. Crystalloid (NS or LR) replacement for hypovolemia
    2. Transfuse pRBCs
    3. Correct Metabolic Acidosis
  4. Discuss Gastric Decontamination with poison control
    1. Whole Bowel Irrigation may be recommended (Polyethylene glycol 25 ml/kg/h for 6-10 hours)
  5. Deferoxamine Chelation
    1. Indications (once hemodynamically stable)
      1. Vomiting, diarhea and signs of shock
      2. Peak iron level >500 mcg/dl (90 mmol/L)
      3. Peak iron level >350 mcg/dl AND symptomatic
      4. Pills seen on abdominal XRay
    2. Protocol
      1. Deferoxamine started at 5 mg/kg/h and observe for Hypotension over the subsequent hour
      2. May titrate to a maximum of 15 mg/kg/h while closely observing for Hypotension
        1. Some cases have used doses as high as 50 mg/kg/h in very severe Poisonings
      3. Obtain iron levels every 2-3 hours
        1. Discontinue Deferoxamine when iron level <350 mcg/dl (62 mmol/L) and asymptomatic
  • Prognosis
  1. Serum Iron at 2-6 hours after ingestion
    1. Serum Iron <300 mcg/dl predicts benign course
    2. Serum Iron >500 mcg/dl predicts severe course
  • References
  1. Gossman (2016) Emergency Medicine Oral Board Review, p. 207-9
  2. (2016) CALS Manual, 14th ed, I-137