Iron Toxicity in Emergency Medicine 

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

Background

Iron overdose has been one of the leading causes of death caused by toxicological agents in children younger than 6 years. Iron is used as a pediatric or prenatal vitamin supplement and for treatment of anemia. Iron is particularly tempting to young children because it appears similar to candy. Patients with anemias that require frequent blood transfusions also are at risk for developing chronic iron toxicity.

Iron overload may develop chronically as well, especially in patients requiring multiple transfusions of red blood cells. This condition develops in patients with sickle cell disease, thalassemia, and myelodysplastic syndromes.

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Pathophysiology

Iron toxicity can be classified as corrosive or cellular.

  • Corrosive toxicity: Iron is an extremely corrosive substance to the GI tract. It acts on the mucosal tissues and can manifest with nausea, vomiting, abdominal pain, hematemesis, and diarrhea; patients may become hypovolemic because of significant fluid and blood loss.
  • Cellular toxicity: The absorption of excessive quantities of ingested iron results in systemic iron toxicity. Severe overdose causes impaired oxidative phosphorylation and mitochondrial dysfunction, which can result in cellular death. The liver is one of the organs most affected by iron toxicity, but other organs such as the heart, kidneys, lungs, and the hematologic systems also may be impaired.
  • End result of corrosive and cellular toxicity is significant metabolic acidosis due to several factors.
    • Hypoperfusion due to significant volume loss, vasodilatation, and negative inotropic effect of iron will result in lactic acidosis.
    • Inhibition of oxidative phosphorylation will promote anaerobic metabolism.

Individuals demonstrate signs of GI toxicity after ingestion of more than 20 mg/kg. Moderate intoxication occurs when ingestion of elemental iron exceeds 40 mg/kg. Ingestions exceeding 60 mg/kg can cause severe toxicity and may be lethal.

Suggested doses are based on calculation of the amount of elemental iron. Different iron preparations (salts) contain different amounts of elemental iron.

  • Fumarate - 33%
  • Sulfate - 20%
  • Gluconate - 12%

Chronic iron overload may deposit iron into organs such as the liver and heart, which may cause death due to myocardial siderosis.

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Epidemiology

Frequency

United States

More than 20,000 children accidentally ingested iron in 1995.[1] Iron was the most common cause of childhood mortality due to nonintentional ingestion. The incidence of iron poisoning has decreased dramatically.

Mortality/Morbidity

Iron poisoning may result in mortality or short-term and long-term morbidity.

Sex

Pregnant patients are at increased risk due to availability of prenatal vitamins and iron supplements in addition to the emotional stress that pregnancy can precipitate.

Age

Iron overdose is one of the leading causes of fatality from toxicological agents in children younger than 6 years.

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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
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  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].

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  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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