Iron Toxicity

The answer first

Iron toxicity is a leading cause of paediatric poisoning death and a recurrent cause of deliberate self-harm in adults. The FRACP candidate must defend the five-stage clinical course of iron poisoning, the thresholds for decontamination and chelation (serum iron greater than 500 micrograms/dL or 90 micromol/L, or symptomatic patients with evidence of toxicity), and the role of whole bowel irrigation when tablets are visible on imaging. Deferoxamine (desferrioxamine) is the chelator of choice: 15 mg/kg/hour IV initially, titrated to clinical response and urinary colour change (the vin rose urine indicates iron-deferoxamine complex excretion). [3] [5]

The answer-first synthesis is: assess airway, breathing, circulation; obtain history (preparation, dose, timing); measure serum iron at 4-6 hours; perform abdominal X-ray for retained tablets; decontaminate with whole bowel irrigation (polyethylene glycol 1-2 L/hour via nasogastric tube in adults, 20-40 mL/kg/hour in children) when radiopaque tablets are visible; start deferoxamine early when indicated (serum iron greater than 500 micrograms/dL, symptomatic, metabolic acidosis, shock, or persistently high iron level); and anticipate the biphasic clinical course (gastrointestinal toxicity at 6 hours, systemic toxicity at 12-24 hours, hepatic failure at 2-5 days). [3] [7]

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1. [1]Hoegberg LCG, Shepherd G, Wood DM et al. Systematic review on the use of activated charcoal for gastrointestinal decontamination following acute oral overdose Clinical toxicology (Philadelphia, Pa.), 2021.PMID 34424785
2. [2]Hoegberg LCG, Gosselin S, Buckley NA et al. Recommendations from the Clinical Toxicology Recommendations Collaborative on the administration of activated charcoal in acute oral overdose Clinical toxicology (Philadelphia, Pa.), 2026.PMID 41906697
3. [3]Baranwal AK, Singhi SC Acute iron poisoning: management guidelines Indian pediatrics, 2003.PMID 12824662
4. [4]Mann KV, Picciotti MA, Spevack TA et al. Management of acute iron overdose Clinical pharmacy, 1989.PMID 2663331
5. [5]Bourbon Ruão M, Pestana I, Passos R et al. Acute Iron Poisoning: A Case of Fulminant Hepatic Failure Acta medica portuguesa, 2024.PMID 38848701
6. [6]Position paper: whole bowel irrigation Journal of toxicology. Clinical toxicology, 2004.PMID 15533024
7. [7]Ornillo C, Harbord N Fundaments of Toxicology-Approach to the Poisoned Patient Advances in chronic kidney disease, 2020.PMID 32147001
8. [8]Tran T, Wax JR, Philput C et al. Intentional iron overdose in pregnancy--management and outcome The Journal of emergency medicine, 2000.PMID 10699527
9. [9]Putta Nagarajan HD, Ramamoorthy RV, Vishwanath N et al. Fulminant Hepatic Failure Following Intentional Iron Overdose-A Case Report Clinical case reports, 2025.PMID 40308484