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Welcome to OHSU talk shorts.Obtain ion concentration, check acid base status and look for visible ion pills on. If concentration is 500 micrograms per deciliter or greater, treatment with deferoxamine and began whole bowel irrigation.If a patient reports iron ingestion and at any time develops metabolic acidosis or hemodynamic instability with hypotension and tachycardia, send serum iron concentration and begin deferoxamine infusion with whole bowel irrigation and disposition to the ICU.Profound toxicity develops from hypovolemia vasodilation, poor cardiac output with decreased tissue perfusion, resulting in a worsening metabolic acidosis.A dose of 20 to 40mg/kg can cause GI symptoms like abdominal pain, nausea, vomiting, and diarrhea, potentially even some hematemesis.While practice patterns vary in general for ion concentrations over 500 micrograms per deciliter, deferoxamine chelation is. Note that a fourhour iron level will give you a steady state of concentration.However, for the sick patient, don't wait for hours to obtain this laboratory test for the ill appearing patient with reported ingestion of a toxic dose of iron, particularly the patient with hypotension and metabolic acidosis.Because the vomiting patient does not tolerate charcoal well, it is probably best to avoid this therapy as. Whole bowel irrigation can be used by installing polyethylene glycol through a nasogastric tube.Dehydration contributes to ill appearance and hypertension in the iron poisoned patient with significant GI symptoms, including hematemesis or hematochezia.The patient can develop anion gap acidosis, hypoglycemia due to sympathomimetic effects, and margination leukocytosis from a stress state.Patients can develop lethargy and coma, worsening GI bleed, acute kidney injury, and pulmonary edema.Stage five, which rarely manifests in patients, can include gastric scarring, pyloric stenosis, and small bowel stricture.Note that iron carbonyl and iron polysaccharide contained in many of the newer iron formulations do not typically cause toxicity.I've deferoxamine can cause hypertension, so this infusion will be increased over time and titrated to the ability of the patient's blood pressure to tolerate infusion.Ongoing cellular toxicity due to iron's effect at blocking oxidative phosphorylation continues.On her arrival, you note she is tearful, she's actively vomiting, and you note some blood tinge to her emesis.This can develop from Mallory Weiss tears or from true mucosal irritation.First, you should provide IV fluid resuscitation through two large bore peripheral IVs.Iron is not absorbed by activated charcoal in the stomach, so it is not generally recommended, although some providers have used charcoal in serious cases.Acknowledging that the pH in the duodenum may make adsorption of iron to activated charcoal more successful.The patient developed some worsening hypertension in the Ed, so it was continued on IV fluids and started on norepinephrine.The color of her urine, initially rose color had become clear, norepinephrine was weaned off overnight, and her deferoxamine infusion was dropped the next day.Let's review the ion treatment algorithm for the asymptomatic patient with a history of small ingestion of under 20mg/kg.The patient can be disposed home or to a psychiatric care facility, as proper for ingestion of more than 20mg/kg or if GI symptoms are present.Because its sulfate has an S, we divide it by five to obtain the iron content per tablet.She's a 60-kilogram patient, so her dose is approximately 100mg/kg.A dose of 60mg/kg can cause more serious effects like hypotension, tachycardia.Anion gap acidosis, hyperglycemia, and leukocytosis.In serious ingestion, such as this one, the infusion may be slowed to 5mg/kg per hour as needed.You might consider treating with norepinephrine if hypotension is not responsive to fluids or is worsening.So, if you're starting a deferoxamine infusion in the emergency department, consider reminding your inpatient colleagues about this.

Welcome to OHSU talk shorts. I'm Peter Opinion toxicology fellow at OHSU. Today we will be
discussing the basics of the emergency management of iron toxicity. You're working a busy shift
when you receive an EMS call that a 17-year-old female is in or out with hematemesis after
ingesting a bottle of her aunt's iron pills. You rally a team to the resuscitation area and realize
you need to think quickly about how to manage this case. On her arrival, you note she is tearful,
she's actively vomiting, and you note some blood tinge to her emesis. Her heart rate is 117
beats per minute. Her blood pressure is 102 over 76. Ems hands you an empty bottle. You note
the pills are 325mg each of ferrous sulfate. How much iron did she take? Iron pills come in
several forms. A useful mnemonic to remember is 357 Magnum is a fast-shooting gun. F is for
ferrous fumarate, which has one third elemental iron. S is for ferrous sulfate, which has one fifth
elemental iron. And G is for ferrous gluconate, which has one seventh elemental iron. So, we
can figure out how much iron is in each tablet by using this mnemonic. As an example, this
patient took tabs having 325mg of ferrous sulfate. Because its sulfate has an S, we divide it by
five to obtain the iron content per tablet. If each pill has 65mg of elemental iron and she took
100 pills, she took 6.5g of iron.
She's a 60-kilogram patient, so her dose is approximately 100mg/kg. Note that iron carbonyl
and iron polysaccharide contained in many of the newer iron formulations do not typically cause
toxicity. A dose of 20 to 40mg/kg can cause GI symptoms like abdominal pain, nausea, vomiting,
and diarrhea, potentially even some hematemesis. This can develop from Mallory Weiss tears
or from true mucosal irritation. A dose of 60mg/kg can cause more serious effects like
hypotension, tachycardia. Anion gap acidosis, hyperglycemia, and leukocytosis. A dose of
100mg/kg can be lethal. Back to our patience. What are the first steps in management? First,
you should provide IV fluid resuscitation through two large bore peripheral IVs. Antiemetics can
be provided as well. Do you do this? And her heart rate improves to 96 beats per minute and
blood pressure to 110 over 82. She stops vomiting but continues to complain of abdominal pain.
You can consider obtaining a QB since iron tablets can be radiopaque. Sending an ion
concentration may help management. While practice patterns vary in general for ion
concentrations over 500 micrograms per deciliter, deferoxamine chelation is. Note that a fourhour iron level will give you a steady state of concentration. So, we repeat iron concentration
can be performed at four hours post ingestion. However, for the sick patient, don't wait for hours
to obtain this laboratory test for the ill appearing patient with reported ingestion of a toxic dose of
iron, particularly the patient with hypotension and metabolic acidosis. Iv deferoxamine should be
started without delay, especially since an iron concentration may be a send out test in many
hospitals.
I've deferoxamine can cause hypertension, so this infusion will be increased over time and
titrated to the ability of the patient's blood pressure to tolerate infusion. Most start the infusion at
15mg/kg per hour and titrate up to 45mg/kg per hour. In serious ingestion, such as this one, the
infusion may be slowed to 5mg/kg per hour as needed. You might consider treating with
norepinephrine if hypotension is not responsive to fluids or is worsening. Deferoxamine is not a
benign therapy. The patient should get no more than eight grams in a 24-hour period. Most
patients will improve within 24 hours. But be aware that the use of deferoxamine for more than
24 hours can cause pulmonary toxicity. So, if you're starting a deferoxamine infusion in the
emergency department, consider reminding your inpatient colleagues about this. Note that the
urine will turn a reddish pink rose color during treatment. Gastric lavage comes with the risk of
GI perforation. Because most patients have had repeated vomiting, many toxicologists
recommend against lavage. Iron is not absorbed by activated charcoal in the stomach, so it is
not generally recommended, although some providers have used charcoal in serious cases.
Acknowledging that the pH in the duodenum may make adsorption of iron to activated charcoal
more successful. Because the vomiting patient does not tolerate charcoal well, it is probably
best to avoid this therapy as. Whole bowel irrigation can be used by installing polyethylene
glycol through a nasogastric tube.
This is recommended ingestions with potential to cause serious toxicity, such as ingestions of at
least 60mg/kg. For adults at a rate of 1.5 to 2l per hour. For children under six, use 500ml. For
children 6 to 12 years use one liter per hour for children over 12. Use 1.5l per hour. There are
five stages of iron toxicity. The first stage is characterized by nausea, vomiting, abdominal pain,
and diarrhea. Dehydration contributes to ill appearance and hypertension in the iron poisoned
patient with significant GI symptoms, including hematemesis or hematochezia. Blood loss can
contribute to hypertension. If there are no GI symptoms in the first six hours of ingestion, serious
iron toxicity is unlikely. Late phase one signs are hypotension, tachycardia, and. The patient can
develop anion gap acidosis, hypoglycemia due to sympathomimetic effects, and margination
leukocytosis from a stress state. The second or latent stage, refers to the period 6 to 24 hours
after resolution of the GI. Symptoms. Ongoing cellular toxicity due to iron's effect at blocking
oxidative phosphorylation continues. In the third stage. Profound toxicity develops from
hypovolemia vasodilation, poor cardiac output with decreased tissue perfusion, resulting in a
worsening metabolic acidosis. Patients can develop lethargy and coma, worsening GI bleed,
acute kidney injury, and pulmonary edema. The fourth stage is characterized by hepatic failure,
which can occur 2 to 3 days after ingestion. Stage five, which rarely manifests in patients, can
include gastric scarring, pyloric stenosis, and small bowel stricture.
Let's return to our case. The patient is started on 15mg/kg per hour of deferoxamine and whole
bowel irrigation. Via Ng tube at 1.5l per. The patient developed some worsening hypertension in
the Ed, so it was continued on IV fluids and started on norepinephrine. She was admitted to the
mice overnight, and Micu team was able to increase her rate to 45mg. Milligram per hour. Within
16 hours, the patient had resolution of her hypertension. The color of her urine, initially rose
color had become clear, norepinephrine was weaned off overnight, and her deferoxamine
infusion was dropped the next day. She was after dispositioned to an inpatient psychiatric
facility. Let's review the ion treatment algorithm for the asymptomatic patient with a history of
small ingestion of under 20mg/kg. If no GI symptoms develop within the first six hours. The
patient can be disposed home or to a psychiatric care facility, as proper for ingestion of more
than 20mg/kg or if GI symptoms are present. Obtain ion concentration, check acid base status
and look for visible ion pills on. If concentration is 500 micrograms per deciliter or greater,
treatment with deferoxamine and began whole bowel irrigation. If a patient reports iron ingestion
and at any time develops metabolic acidosis or hemodynamic instability with hypotension and
tachycardia, send serum iron concentration and begin deferoxamine infusion with whole bowel
irrigation and disposition to the ICU. Thank you for tuning in to OHSU Talk Shor