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Iron - Dr. Beuhler

2/6/2014

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Picture
Iron

    - Metals in salt form cause VOMITING
    - 2+ ferrous sulfate in absorbable state → 3+ state for storage/transfer

Chewable tablets
    - 10-18mg/tab
    - Hard to overdose on these - “minimally toxic”

Iron carbonyl
    - elemental iron
    - low toxicity

Iron filings in hand warmers → if ingested, could be toxic

Prenatal vitamins
    - greatest morbidity
    - look like candy

  • When considering overdose, must calculate the dose of elemental Fe ingested
  • Varies based on the substance, so just look up -- or Call Poison Control!
  • Toxic dose starts at 20-60mg/kg
  • >60mg/kg -- concern 
  • If no vomiting associated, probably ok and not at toxic level

Injuries
  • GI -- mucosal damage, ulceration, perforation, hemorrhage, strictures
  • CV -- decreased cardiac contractility, vessel injury, 3rd spacing of fluid
  • Liver -- a hepatotoxin -- periportal necrosis, sequestered in 1st pass metab, coagulopathy, hyperammonemia, hypoglycemia


5 stages of toxicity

1. ingestion to 6h

    - vomiting!!
    - abd pain
    - diarrhea
    - melena/hematemesis
    - bowel wall necrosis/infarct

2. 6h - 24h

    - quiescent stage
    - symptoms appear to resolve
    - continued worsening acidosis
    - if ingestion was small → course usually stops here
    - if ingestion was large → this stage is sometimes skipped and go onto more badness

3. 12h - 48h

    - crash
    - CV, Liver, GI, ARDS, CNS lethergy/coma, Acidosis

4. 2d - 3d

    - independent of severity of stage 3
    - fulminant hepatic failure
    - >1000 iron level

5. weeks later

    - mucosal injuries/strictures

Iron Levels
  • Iron levels peak around 2-6 hr, longer if enteric coated tablets
  • Level not a reliable indicator of toxicity
  • 300-500 -- systemic toxicity
  • >500 → treat
  • Get a level before started deferoxamine

Workup


   - electrolytes -- AGMA
   - coags if bleeding
   - LFTs if sick
   - APAP level for intentional ingestion -- think about synergy

   - x-rays -- abd → see pills sometimes

Management

  • obs for 6 h if asxs → ok → home
  • no GI or acidosis
  • if sxs, esp GI or acidosis → admit for obs
  • get iron level
  • fluid resuscitation
  • no lavage/charcoal/ipecac/bicarb
  • may consider whole bowel irrigation if positive xray
  • Deferoxamine
  • specific antedote for iron
  • no heme/cytochrome iron binding

        use:

            hx of sxs, pos xrays, super high iron level
            100mg binds 10mg iron

        IV admin -- 15mg/kg/hr for rate but may not get in enough

        Side Effects:

            hypotension, tachycardia, diuresis

            visual/ototoxicity, abd pain, fever, diarrhea

            increased risk for yersenia enterocolitica sepsis

        stop when acidosis resolves

Core Concepts:


    elemental dose is what’s toxic

    no charcoal for tx

    look for anion gap metabolic acidosis

    check an xray for pills, but if it’s negative doesn’t mean pt isn’t sick

    there’s a quiescent phase of toxicity

    deferoxamine is an option for iron chelation

    pay attention to units used to quantify iron --usually in dL


       


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  • RESIDENCY
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    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
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    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
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  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction