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Iron Toxicity Treatment & Management

  • Author: Clifford S Spanierman, MD; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Dec 04, 2015
 

Prehospital Care

In patients with acute iron overdose, intravenous access should be established immediately. Patients who are hypovolemic should receive fluid boluses of 20 mL/kg of normal saline or lactated Ringer (LR) solution. Provide oxygen to patients in shock.

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Emergency Department Care

Assume that symptomatic patients are hypovolemic. Administer vigorous volume therapy with isotonic crystalloids (eg, normal saline, LR solution) in 20 mL/kg boluses to attain and maintain hemodynamic stability. Give supplemental oxygen.

Gastric lavage with a large-bore orogastric tube may remove iron from the stomach. Ideally, lavage should be performed 1-2 hours postingestion, although later use may be appropriate if evidence of iron products in the stomach is observed on a radiograph. However, iron has a gelatinous texture and may be difficult to remove by lavage. Whole-bowel irrigation may be used in patients with a radiopacity on kidneys, ureters, bladder (KUB) plain radiographs, until the radiopacity clears.

Ipecac has been used for gastric decontamination in patients with iron poisoning. Ipecac might be considered when it can be administered within 60 minutes of iron ingestion, in an alert patient who has ingested a very large amount of iron. Ipecac is not used routinely for iron removal because it can mask clinical signs of iron toxicity (vomiting). Significant iron overdose may cause hypotension and unstable vital signs, in which case ipecac is contraindicated, as it may endanger the patient's airway as an aspiration risk.

The American Academy of Clinical Toxicology advises that the routine administration of ipecac in the emergency department should definitely be avoided. Some reports suggest that ipecac may offer possible benefits in rare situations involving iron poisoning; this may be a moot point, however, since the availability of ipecac is rapidly diminishing.[3] In any case, iron toxicity itself typically causes vomiting, because of its caustic effect on the gastrointestinal mucosa, so iron-poisoned patients routinely perform self-decontamination even without ipecac.

Activated charcoal does not bind iron. However, it should be utilized if co-ingestants are suspected.

Asymptomatic patients observed for 6 hours with serum iron levels less than 300-350 mcg/dL may be discharged.

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Consultations

Consultation with a toxicologist is recommended. Obtain a gastroenterology consultation for patients who have large iron bezoars.

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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

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, Undersea and Hyperbaric Medical Society, Wilderness Medical Society, American College of Occupational and Environmental 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.

Additional Contributors

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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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

  2. Mowry JB, Spyker DA, Brooks DE, McMillan N, Schauben JL. 2014 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd Annual Report. Clin Toxicol (Phila). 2015 Dec. 53 (10):962-1147. [Medline]. [Full Text].

  3. [Guideline] Höjer J, Troutman WG, Hoppu K, Erdman A, Benson BE, Mégarbane B, et al. Position paper update: ipecac syrup for gastrointestinal decontamination. Clin Toxicol (Phila). 2013 Mar. 51(3):134-9. [Medline].

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

  5. Sankar J, Shukla A, Khurana R, Dubey N. Near fatal iron intoxication managed conservatively. BMJ Case Rep. 2013 Jan 31. 2013:[Medline].

  6. 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].

  7. Gumber MR, Kute VB, Shah PR, et al. Successful Treatment of Severe Iron Intoxication with Gastrointestinal Decontamination, Deferoxamine, and Hemodialysis. Ren Fail. 2013 May 1. [Medline].

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

  9. 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].

  10. 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].

  11. 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].

  12. 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. 2008 Jul-Sep. 71(3):345-6. [Medline].

 
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