Critical Alerts

• Iron poisoning can be rapidly fatal - especially in children
• Four phases of toxicity - watch for deceptive "quiet phase"
• Abdominal X-ray may show radiopaque tablets
• Deferoxamine is the antidote - start early if severe
• GI bleeding and acidosis are hallmarks of severe toxicity

Key Diagnostics

• Serum iron level (peak at 4-6 hours)
• TIBC (total iron binding capacity) - less useful acutely
• ABG/VBG (metabolic acidosis)
• CBC, coagulation panel
• BMP (glucose, renal function)
• Abdominal X-ray (radiopaque pills)

Emergency Treatments

• GI decontamination: Whole bowel irrigation if intact tablets on X-ray
• Deferoxamine: 15 mg/kg/hr IV for severe toxicity
• IV fluids: Aggressive resuscitation for hypovolemia
• Bicarbonate: For severe metabolic acidosis
• Avoid charcoal: Does not bind iron

Iron overdose is a potentially life-threatening toxicity resulting from ingestion of elemental iron, typically from iron supplement tablets. It is particularly dangerous in children due to the availability of attractive-looking iron supplements. The toxic effects are mediated by free iron's corrosive action on the GI tract and cellular toxicity from oxidative damage.

Iron Content of Common Preparations

Toxicity Thresholds

Epidemiology

• Peak incidence: Children ages 1-3 years (accidental ingestion)
• Leading cause: Pediatric poisoning death from pharmaceuticals (historically)
• Adults: Often intentional overdose
• Improved safety: Unit-dose packaging has reduced pediatric deaths

Critical Findings

Prognostic Indicators

Poor Prognosis

• Serum iron >1000 mcg/dL
• pH <7.1
• Shock unresponsive to fluids
• Hepatic failure (elevated INR, transaminases)
• Coma

Other Toxic Ingestions

Other Causes of GI Bleeding with Shock

• Upper GI bleed (ulcer, varices)
• Lower GI bleed
• Ischemic bowel
• GI perforation

Initial Assessment

Key History

• Exact product ingested
• Number of pills taken
• Time of ingestion
• Intentional vs accidental
• Co-ingestants

Calculate Elemental Iron Dose

Elemental iron (mg) = Number of tablets × Elemental iron per tablet
Dose (mg/kg) = Total elemental iron ÷ Patient weight (kg)

Laboratory Studies

Serum Iron Interpretation

Important Notes:

• Peak level at 4-6 hours post-ingestion
• Level drawn <4 hours may underestimate severity
• Enteric-coated preparations delay absorption
• Level AND clinical status both matter

Imaging

Abdominal X-ray

• Iron tablets are radiopaque
• Useful to confirm ingestion
• Guide need for whole bowel irrigation
• May show pill fragments, bezoar
• Normal X-ray does not exclude significant ingestion (liquid iron, dissolved tablets)

ICU Admission Criteria

• Serum iron >500 mcg/dL
• Any systemic symptoms (shock, altered mental status)
• Metabolic acidosis
• Coagulopathy or hepatotoxicity
• Need for deferoxamine infusion
• Significant GI bleeding

Observation Unit/Ward

• Serum iron 300-500 mcg/dL with mild symptoms
• Asymptomatic with borderline levels
• Post-decontamination observation

Discharge Criteria (Low-Risk Ingestions)

• Ingestion <20 mg/kg elemental iron
• Asymptomatic at 6 hours
• Serum iron <300 mcg/dL
• Normal acid-base status
• Psychiatric evaluation if intentional (before discharge)

Follow-up Considerations

Understanding Iron Poisoning

• Iron supplements can be very dangerous if too much is taken
• Symptoms may appear to improve then worsen significantly
• Treatment in hospital is essential for significant ingestions

Prevention (for Caregivers)

Child Safety

• Store iron supplements out of reach of children
• Use child-resistant containers
• Supervise medication administration
• Teach children that pills are not candy

Signs of Worsening

Return immediately if:

• Vomiting blood
• Bloody diarrhea
• Increasing abdominal pain
• Confusion or drowsiness
• Fainting or dizziness

Pediatric Patients

• More common accidental ingestion
• Lower toxic threshold (lower weight)
• Often more severe outcomes historically
• Calculate dose carefully in mg/kg

Pregnancy

• Iron supplements commonly prescribed
• Deferoxamine crosses placenta but is life-saving
• Treat maternal toxicity aggressively
• Fetal outcomes dependent on maternal outcomes

Enteric-Coated Preparations

• Delayed absorption (peak may be 8-12 hours)
• May not show on X-ray if dissolved
• WBI particularly important
• Multiple serum iron levels recommended

Chronic Iron Overload States

• Hemochromatosis, transfusion-dependent patients
• Already have elevated iron stores
• May be more susceptible to acute toxicity

Performance Indicators

Documentation Requirements

• Product and amount ingested
• Elemental iron dose calculated (mg/kg)
• Time of ingestion
• Serial serum iron levels
• Acid-base status
• Deferoxamine administration details
• Response to treatment
• Disposition rationale

Diagnostic Pearls

1. Calculate elemental iron dose - determines expected severity
2. "Quiet phase" is dangerous - don't be falsely reassured
3. Peak iron level at 4-6 hours - draw level appropriately
4. X-ray may show pills - helpful for WBI decision
5. Acidosis correlates with severity - check ABG

Treatment Pearls

1. Charcoal does NOT work for iron - don't use it
2. Deferoxamine for severe toxicity - start early
3. WBI for visible pills on X-ray
4. Watch for hypotension with deferoxamine - infuse slowly
5. Vin rosé urine confirms deferoxamine is working

Disposition Pearls

1. Observe 6 hours if any GI symptoms
2. ICU for any systemic symptoms or high iron level
3. Psychiatric evaluation for intentional overdose
4. Warn about late strictures (2-6 weeks)
5. Poison control is helpful - call them