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Key Features

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  • Three common formulations with varying amounts of elemental iron

    • Ferrous fumarate (33%)

    • Ferrous sulfate (20%)

    • Ferrous gluconate (12%)

  • Typically, doses of more than 20 mg/kg of elemental iron cause symptoms

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Clinical Findings

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  • Five stages of intoxication may occur in iron poisoning

    • Hemorrhagic gastroenteritis, which occurs 30–60 minutes after ingestion and may be associated with shock, acidosis, coagulation defects, and coma; this phase usually lasts 4–6 hours

    • Phase of improvement, lasting 2–12 hours, during which patient looks better

    • Delayed shock, which may occur 12–48 hours after ingestion; metabolic acidosis, fever, leukocytosis, and coma may also be present

    • Liver damage with hepatic failure

    • Residual pyloric stenosis, which may develop about 4 weeks after the ingestion

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Diagnosis

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  • Once iron is absorbed from the GI tract, it is not normally eliminated in feces but may be partially excreted in the urine, giving it a red color prior to chelation

  • A reddish discoloration of the urine suggests a serum iron level > 350 mg/dL but is neither sensitive nor specific

  • Urinary output should be monitored and urine sediment examined for evidence of renal tubular damage

  • Initial laboratory studies should include

    • Blood typing and cross-matching

    • Total protein

    • Serum iron, sodium, potassium, and chloride

    • PCO2

    • pH

    • Liver function tests

  • Serum iron levels fall rapidly even if deferoxamine is not given

  • After the acute episode, liver function studies and an upper GI series are indicated to rule out residual damage

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Treatment

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  • GI decontamination is based on clinical assessment

  • Gastric lavage and whole bowel irrigation should be considered in potentially life-threatening overdoses

  • Shock is treated in the usual manner

  • Deferoxamine

    • Specific chelating agent for iron, is a useful adjunct in the treatment of severe iron poisoning

    • Indications

      • Metabolic acidosis

      • Persistent symptoms

      • Shock

      • Serum iron determination cannot be obtained readily, or if the peak serum iron exceeds 400 mcg/dL (62.6 μmol/L) at 4–5 hours after ingestion

    • Dosages

      • For shock: 15 mg/kg/h intravenously; infusion rates up to 35 mg/kg/h have been used in life-threatening poisonings

      • If intravenous access unavailable, give 90 mg/kg intramuscularly every 8 hours (maximum, 1 g); procedure is painful

    • May be discontinued after 12–24 hours if the acidosis has resolved and the patient is improving

    • Side effects

      • Acute respiratory distress syndrome (ARDS) if given for more than 24 hours

      • Rapid intravenous administration can cause hypotension, facial flushing, urticaria, tachycardia, and shock

      • Contraindicated in patients with renal failure unless dialysis can be used

  • Hemodialysis, peritoneal dialysis, or exchange transfusion can be used to increase the excretion of the dialyzable complex

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