Episode 229: Iron Poisoning

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Episode 229: Iron Poisoning

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Iron overdose in the ED: five stages, elemental iron math, decontamination, and deferoxamine. Hosts: Brian Chastain, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Iron_Poisoning.mp3 Download Leave a Comment Tags: Toxicology Podcast Video Show Notes Core EM Modular CME Course Maximize your commute with the new Core EM Modular CME Course, featuring the most essential content distilled from our top-rated podcast episodes. This course offers 12 audio-based modules packed with pearls! Information and link below. Course Highlights: Credit: 12.5 AMA PRA Category 1 Credits™Curriculum: Comprehensive coverage of Core Emergency Medicine, with 12 modules spanning from Critical Care to Pediatrics.Cost: Free for NYU Learners$250 for Non-NYU Learners Click Here to Register and Begin Module 1 Iron Poisoning Stages at a Glance StageTimingWhat’s happening1 · GI30 min–6 hDirect corrosive GI injury; abd pain, vomiting2 · Latent6–24 hGI sx improve; iron redistributing into tissues3 · Shock / acidosis6–72 hProfound metabolic acidosis → shock, MSOF4 · Hepatotoxicity12–96 hHepatotoxicity → fulminant liver failure5 · GI scarring2–8 wksGastric outlet obstruction, GI tract scarring The Case 31M w/ hx depression, anxiety; found minimally responsive at home by familyEMS: HR 67, SpO2 96% on 2 L NC, BP 46/21; withdraws to pain, not opening eyes → 2 L IVF + push-dose epi en routeED: BP ↑ to 90/61, other VS unchanged; dried vomit on lips/shirt; breathing comfortably, protecting airwayPOC VBG: pH 7.24, pCO2 33, pO2 25, HCO3 14, lactate 2.5ECG: NSR, otherwise unremarkable → get an ECG in any possible toxic ingestionAdditional 30 mL/kg bolus + norepi gttFamily arrives → bottle of iron pills under the pt’s bed Pathophysiology Free iron = multisystem oxidative injuryPrimary mechanism: free radical generation + lipid peroxidation → damages cellular and mitochondrial membranes throughout the bodyProfound metabolic acidosis via 2 routes: uncoupled oxidative phosphorylation → anaerobic metabolism → lactate; Fe³⁺ reacts w/ water → releases 3 H⁺ → excess acidDirect mucosal necrosis in the gut (corrosive injury)Negative inotrope on the myocardium → hypotension, cardiogenic shock in large ingestions Clinical Stages Classic progression after large ingestions; stages overlap and pts can present anywhere along the timelineStage 1, GI (30 min–6 h): direct GI tract injury; abd pain, vomiting. Persistent vomiting = very sensitive indicator of a serious ingestionStage 2, latent (6–24 h): GI sx improve, but iron is redistributing into the tissues → ongoing damageThe latent-phase trap: pts look like they’re turning the corner right before they crump. Contrast: pts never symptomatic >6 h after ingestion are unlikely to develop toxicity (AAPCC 2005); GI sx that improve ≠ never symptomaticStage 3, shock (6–72 h): tissue iron → profound acidosis → shock, MSOFStage 4, hepatotoxicity (12–96 h): hepatotoxicity → fulminant liver failureStage 5, GI scarring (2–8 wks): gastric outlet obstruction, GI tract scarring from the initial corrosive injury Diagnosis / Workup Imaging Emergent plain-film abd XR in any suspected iron ingestion → intact adult iron tabs are radiopaqueConfirms pills still in the stomach/GI tract → helps decide on WBINegative XR ≠ no ingestion: chewables, liquid formulations and already-dissolved tabs often don’t show up Serum Iron Draw 4–6 h post-ingestion for regular formulations, ~8 h for extended releaseOften hard to interpret → time of ingestion and formulation frequently unknown>500 mcg/dL → serious systemic toxicity>1,000 mcg/dL → very significant mortality Elemental Iron Math Toxicity tracks the elemental iron dose, not the mass of the pill SaltElemental FePer 325 mg tabFerrous sulfate~20%~65 mgFerrous fumarate~33%106 mgFerrous gluconate~12%~36–38 mg <20 mg/kg elemental Fe → usually asymptomatic20–60 mg/kg → GI sx likely; systemic toxicity possible, esp. at the upper end>60 mg/kg → threshold for serious toxicity, possible deathAAPCC out-of-hospital guideline: refer to an ED for ≥40 mg/kg elemental Fe (adult ferrous salt formulations) or severe/persistent sx; any self-harm ingestion → ED regardless of amount (Manoguerra 2005)AAPCC: children’s chewable vitamins w/ iron, and unintentional carbonyl iron or polysaccharide-iron complex ingestions → home obs w/ f/u Management Decontamination Activated charcoal: no role. Iron is a metal → doesn’t bind; ↑ aspiration and other complicationsWhole bowel irrigation (WBI) = main decontamination strategy, esp. w/ pills on XR → flush tablets before further GI injury and systemic absorptionPEG-ELS (polyethylene glycol electrolyte solution) until rectal effluent is clear; large volume → often via NG tubePEG-ELS rates: 1.5–2 L/h adolescents/adults (as on air); peds 500 mL/h (9 mo–6 y), 1 L/h (6–12 y) (AACT/EAPCCT 1997)AACT...

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