Management of acute iron poisoning in a toddler

Severity. An estimated ingestion of more than 60 mg/kg elemental iron, symptoms, blood sugar above 150 mg/dL, a leukocyte count above 15,000 and iron tablets on the abdominal radiograph indicate severe toxicity and the need for chelation; this child is symptomatic with a leukocytosis and visible tablets. The serum iron may not be fully reliable for decisions, and serum iron concentrations do not necessarily relate to acute toxicity.^[5][10]

Resuscitation. Aggressive management of shock and organ failure, preferably in a paediatric intensive care unit, is a mainstay of management.^[5]

Decontamination. There is no role for activated charcoal in iron poisoning.^[6] Whole bowel irrigation was recommended for iron salts as a best-evidence recommendation.^[3]

Chelation. Desferrioxamine infusion at 15 mg/kg/hour in saline; a "vin-rose" urine after desferrioxamine may help but is not seen consistently.^[5] Deferoxamine remains the drug of choice for significant iron poisoning, although its optimal indications, dose, route and duration are unclear.^[7] Prolonged intravenous dosing carries pulmonary and cardiovascular toxicity, and acute respiratory distress syndrome has been linked to desferrioxamine, so it should not be prolonged unnecessarily.^[8][9]

Prognosis and counselling. Shock, coagulopathy, severe acidosis and acute liver failure are poor prognostic indicators, and guardians should be counselled about safe storage of adult iron tablets.^[5] The recognised phases end with gastrointestinal scarring.^[1]