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Acute iron poisoning after ingestion: Rapid overview of emergency management

To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222 for the nearest regional poison control center. Contact information for poison control centers around the world is available at the WHO website and in the UpToDate topic on regional poison control centers (society guideline links).

History

What form of iron was ingested?
- Ferrous gluconate (12% elemental iron)
- Ferrous sulfate (20% elemental iron)
- Ferrous fumarate (33% elemental iron)
How many mg/kg of elemental iron was ingested?
When did the ingestion occur?

Clinical manifestations*

Gastrointestinal (30 minutes to 6 hours)

Abdominal pain
Vomiting (hematemesis) and diarrhea
Melena
Lethargy
Shock (from capillary leak and third spacing)
High anion gap metabolic acidosis

Latent (6 to 24 hours)^¶

Improvement in gastrointestinal symptoms
May have poor perfusion, tachypnea, and/or tachycardia

Shock and metabolic acidosis (6 to 72 hours)

Hypovolemic, distributive, or cardiogenic shock with profound metabolic acidosis
Coagulopathy
Acute kidney injury
Pulmonary dysfunction/respiratory failure
Central nervous system dysfunction

Hepatotoxicity (12 to 96 hours, severity is dose dependent)

Coma
Coagulopathy
Jaundice

Bowel obstruction (2 to 8 weeks, usually gastric outlet obstruction)

Abdominal pain
Vomiting
Dehydration

Diagnosis

The diagnosis of iron poisoning is suspected based upon a history of iron ingestion and clinical manifestations of poisoning. It is confirmed by the presence of visible iron pills on plain abdominal radiograph or an elevated peak serum iron level (≥500 mcg/dL [90 micromol/L]).

Ancillary studies

Symptomatic

All patients
- Plain radiograph of the abdomen
- Plasma glucose
- Serum electrolytes
- BUN and creatinine
- Venous or arterial blood gas
- Peak serum iron level
  - 4 to 6 hours after ingestion of regular iron
  - 8 hours after ingestion of extended-release iron
Moderate to severe poisoning (in addition to above studies)
- ALT, AST, and total bilirubin
- CBC with differential
- PT, PTT, and INR
- Type and screen

Asymptomatic

All patients with more than a trivial overdose
- Peak serum iron level (if ≥500 mcg/dL [90 micromol/L], obtain all studies recommended for moderate or severe poisoning above)
At risk for toxicity (an estimated ingested dose ≥40 mg/kg elemental iron, unknown ingested dose, or an intentional ingestion)
- Plain radiograph of the abdomen
- Plasma glucose
- Serum electrolytes
- BUN and creatinine
- Venous or arterial blood gas

Management

Supportive care: Support airway, breathing, and circulation; treat hypovolemic shock with fluid boluses of normal saline (10 to 20 mL/kg) as needed

Gastrointestinal decontamination: The need for gastrointestinal decontamination is determined by the number and location of iron pills seen on plain radiograph of the abdomen:

Orogastric lavage – For patients with iron pills in the stomach, the risk of gastric lavage usually outweighs the benefit. Lavage may be indicated for patients with moderate to severe poisoning and a large number or iron pills on abdominal radiograph (eg, 20 to 30 pills).
Whole-bowel irrigation – We suggest whole-bowel irrigation rather than no gastrointestinal decontamination for patients who have a significant number of iron pills visible on plain abdominal radiograph^Δ and any one of the following:
- Symptoms of moderate to severe iron poisoning
- High anion gap metabolic acidosis
- Peak serum iron level ≥500 mcg/dL (90 micromol/L)
- Asymptomatic or mildly symptomatic patients with an abdominal radiograph suggesting an estimated ingestion of >60 mg/kg elemental iron
- Patients who have a continued rise in serial serum iron concentrations despite administration of deferoxamine

Deferoxamine: We recommend IV deferoxamine for patients with an oral iron overdose and any one of the following signs of serious poisoning:

Severe symptoms (hypovolemic shock, lethargy/coma, persistent vomiting/diarrhea)
Elevated anion gap metabolic acidosis
Peak serum iron level ≥500 mcg/dL (90 micromol/L)
Estimated ingested dose from visible pills on radiograph ≥60 mg/kg elemental iron

Prior to administration of deferoxamine, consultation with a medical toxicologist and/or regional poison control center is recommended. For details regarding dose and duration of treatment, refer to UpToDate content on acute iron poisoning.

BUN: blood urea nitrogen; ALT: alanine aminotransferase; AST: aspartate aminotransferase; CBC: complete blood count; PT: prothrombin time; PTT: partial thromboplastin time; INR: international normalized ratio; IV: intravenous.

* In patients with moderate to severe iron poisoning, the progression of the clinical phases often overlap and may occur rapidly; the clinical phase should be determined by the patient's clinical and laboratory manifestations, not by the time since the ingestion.

¶ It is critical to differentiate patients who are in the latent phase from those with low-toxicity ingestions who have exhibited only mild gastrointestinal symptoms and for whom toxicity has now resolved. Patients whose gastrointestinal symptoms have improved should be observed and re-evaluated to determine whether they have truly recovered or are progressing to further clinical deterioration.

Δ A significant amount of unabsorbed iron is present when the number of pills seen on abdominal radiograph and the elemental iron content of the product ingested have the potential for worsening toxicity based upon patient weight.

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