Iron Toxicity in Emergency Medicine Clinical Presentation

  • Author: Clifford S Spanierman, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Jul 27, 2011
 

History

  • Alert patients who present without vomiting most likely did not ingest a toxic dose of iron.
  • More than 4 episodes of vomiting suggest significant iron toxicity.
  • Iron ingestions with GI symptoms such as vomiting and diarrhea (especially hemorrhagic)
  • Hemorrhagic gastroenteritis, even in the absence of ingestion
  • Hyperglycemia with metabolic acidosis during or following episodes of abdominal pain and gastroenteritis
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Physical

Iron poisoning is often classified into 5 distinct stages. Understanding the course of poisoning is important, especially the second (recovery) stage, which may lure the physician into a false sense of security and result in premature and inappropriate discharge of a patient.

  • Stage 1 (gastrointestinal)
    • This stage usually occurs within 6 hours after exposure.
    • Nausea and diarrhea, often accompanied by abdominal pain, characterize the gastrointestinal (GI) phase.
    • When the intoxication is severe, a hemorrhagic component is observed in conjunction with gastroenteritis.
    • The combination of fluid and blood loss, with additional third-spacing, may result in hypovolemia or shock.
    • Fatality occurs in a significant percentage of patients during this first phase.
  • Stage 2 (latent)
    • This stage is characterized by resolution of GI symptoms.
    • The patient appears to improve and recover.
    • This deceptive phase usually occurs 6-12 hours after ingestion and may last as long as 24 hours.
    • Metabolic abnormalities during this phase may include hypotension, metabolic acidosis, and coagulopathy.
    • Some patients skip this phase and progress directly to stage 3. Usually, the clinician does not recognize subtle signs of toxicity.
  • Stage 3 (metabolic/cardiovascular)
    • Stage 3 is characterized by metabolic acidosis and cardiovascular symptoms.
    • It is hypothesized that high iron concentrations produce venous pooling and third-spacing of fluids.
    • This phase is also characteristic of CNS symptoms, usually stupor and coma.
    • Most patients die during this phase.
    • It can start very early (6-8 h), depending on severity of exposure, and it can last up to 2 days.
    • The acidosis may indicate failure of other organs, such as the heart and kidneys.
  • Stage 4 (hepatic)
    • Elevated liver enzymes and bilirubin levels are commonly observed with coagulopathy, indicative of hepatic dysfunction.
    • Hypoglycemia may accompany liver dysfunction.
  • Stage 5 (delayed)
    • This stage is characterized by scarring of the healing GI tract. The stomach and/or intestines may be affected, resulting in gastric outlet or intestinal obstruction.
    • This phase usually is experienced weeks after a severe poisoning.
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Contributor Information and Disclosures
Author

Clifford S Spanierman, MD  Consulting Staff, Departments of Emergency Medicine and Pediatrics, Lutheran General Hospital of Oak Brook, Advocate Health System

Disclosure: Nothing to disclose.

Specialty Editor Board

David C Lee, MD  Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School

David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

John G Benitez, MD, MPH  Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

References

  1. Morse SB, Hardwick WE Jr, King WD. Fatal iron intoxication in an infant. South Med J. Oct 1997;90(10):1043-7. [Medline].

  2. Griffith EA, Fallgatter KC, Tantama SS, Tanen DA, Matteucci MJ. Effect of deferasirox on iron absorption in a randomized, placebo-controlled, crossover study in a human model of acute supratherapeutic iron ingestion. Ann Emerg Med. Jul 2011;58(1):69-73. [Medline].

  3. Carlsson M, Cortes D, Jepson S, Kansstrup T. Severe iron intoxication treated with exchange transfusion. Arch Dis Child. April 2008;93(4):321-2. [Medline].

  4. Ng HW, Tse ML, Lau FL, Chu W. Endoscopic removal of iron bezoar following acute overdose. Clin Toxicol (Phila). Nov 2008;46(9):913-5. [Medline].

  5. Haider F, De Carli C, Dhanani S, Sweeny B. Emergency laparoscopic-assisted gastrotomy for the treatment of an iron bezoar. J Laparoendosc Adv Surg Tech A. April 2009;19 Suppl 1:S141-3. [Medline].

  6. Cerezo A, Costan G Gonzale A, Galvez C , Garcia V, Iglesias E, Reye A, et al. Severe esophagitis due to overload of iron tablets. Gastroenterol Hepatol. Oct 2008;31(8):551-2. [Medline].

  7. Valentine K, Mastropietro C, Sarnaik AP. Infantile iron poisonings: challenges in diagnosis and management. Pediatr Crit Care Med. May 2009;10 (3):e31-33. [Medline].

  8. Alymara V, Bourantas D, Chaidos A. Effectiveness and safety of combined iron-chelation therapy with deferoxamine and deferiprone. Hematol J. 2004;5(6):475-9. [Medline].

  9. Atiq M, Dang S, Olden KW, Aduli F. Early endoscopic gastric lavage for acute iron overdose: a novel approach to accidental pill ingestions. Acta Gastroenterol Belg. Jul-Sep 2008;71(3):345-6. [Medline].

  10. Bosse GM. Conservative management of patients with moderately elevated serum iron levels. J Toxicol Clin Toxicol. 1995;33(2):135-40. [Medline].

  11. Cheney K, Gumbiner C, Benson B, Tenenbein M. Survival after a severe iron poisoning treated with intermittent infusions of deferoxamine. J Toxicol Clin Toxicol. 1995;33(1):61-6. [Medline].

  12. Goldberg sl. Novel treatment options for transfusional iron overload in patients with myleodysplatic syndromes. Leuk Res. Dec 2007;31:s16-22. [Medline].

  13. Hershko CM, Link GM, Konijn AM. Iron chelation therapy. Curr Hematol Rep. Mar 2005;4(2):110-6. [Medline].

  14. McGuigan MA. Acute iron poisoning. Pediatr Ann. Jan 1996;25(1):33-8. [Medline].

  15. Mills KC, Curry SC. Acute iron poisoning. Emerg Med Clin North Am. May 1994;12(2):397-413. [Medline].

  16. Palatnick W, Tenenbein M. Leukocytosis, hyperglycemia, vomiting, and positive X-rays are not indicators of severity of iron overdose in adults. Am J Emerg Med. Sep 1996;14(5):454-5. [Medline].

  17. Tenenbein M. Benefits of parenteral deferoxamine for acute iron poisoning. J Toxicol Clin Toxicol. 1996;34(5):485-9. [Medline].

 
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