Iron Toxicity Treatment & Management

Updated: Feb 04, 2019
  • Author: Clifford S Spanierman, MD; Chief Editor: Michael A Miller, MD  more...
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Treatment

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. [4] 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.

Deferoxamine (Desferal) can be used to chelate iron. [5]  Patients who are symptomatic should receive deferoxamine regardless of their iron level. In acute or chronic iron toxicity, chelation therapy with deferoxamine is indicated for patients with serum iron levels >350 mcg/dL who have evidence of toxicity, or levels of >500 mcg/dL regardless of signs or symptoms (see Medication). In patients with significant clinical manifestations of toxicity, chelation therapy should not be delayed while one awaits serum iron levels.

In acute iron poisoning, intramuscular (IM) administration is indicated for patients who are not in shock; intravenous (IV) administration should be reserved for patients in a state of cardiovascular collapse or shock. However, note that rapid IV administration of deferoxamine may itself result in hypotension and shock. For chronic iron overload, administration can be subcutaneous, IV, or IM. Aggressive hydration aids in eliminating chelated iron by maintaining an appropriate urine output.

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

Features of further inpatient care are as follows:

  • Conservative management may be adequate in severe intoxication. [6]

  • Persistently symptomatic patients with serum iron levels higher than 350 mcg/dL should be admitted.

  • Patients who have been hemodynamically unstable, and those with serum iron levels higher than 1000 mcg/dL, should be admitted to a facility that can provide age-appropriate intensive care.

  • Other modalities that may be essential include mechanical ventilation and blood product transfusions.

  • Exchange transfusion has been reported to be successful in management of a case of severe iron poisoning. [7]

  • Hemodialysis has been used in severe intoxications. [8]

  • Iron bezoars may be removed laparoscopically or endoscopically. [9, 10]

 

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Medical Care

 

 

 

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Consultations

Consultation with a toxicologist is recommended. Obtain a gastroenterology consultation for patients who have large iron bezoars. Transfer patients if intensive care or deferoxamine is not available locally.

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