1. Ten minute toxicology: Iron Russell Berger, MD Co-Director Medical Toxicology Cambridge Health Alliance

2. Need to establish right away how many mg/kg of ELEMENTAL IRON may have been ingested. Each formulation of iron has a different percentage of elemental iron: – Ferrous Fumarate: 33% – Ferrous Sulfate: 20% – Ferrous Gluconate: 12%

3. If you aint puking, you aint toxic. Garth Algar: Uhm, Wayne? What do you do if every time you see this one incredible woman, you think you're gonna hurl? Garth Algar Wayne Campbell: I say hurl. If you blow chunks and she comes back, she's yours. But if you spew and she bolts, then it was never meant to be. Wayne Campbell

4. Example A 20 kg child ingests # 10, 300 mg ferrous sulfate tablets. Calculate the mg/kg of elemental iron the child ingested. 10 tablets x 300mg/tablet = 3000 mg total of which 20% is elemental iron = 600mg total elemental iron. Thus, 600mg/20kg = 30mg/kg ingestion.

5. Iron toxicity 20 mg/kg sick 40mg/kg very sick >60 mg/kg very, very sick…die

6. Mechanism of toxicity Direct corrosive effects on the GI tract Iron causes cellular damage and acidosis (mechanism unknown). Iron produces free radicals which are damaging to cell membranes.

7. Stages of Toxicity 1: Acute GI irritation. Hemorrhagic Gastritis/diarrhea 2: Apparent improvement over the next 12 hours 3:Coma, metabolic acidosis, liver failure, sepsis (yersinia) 4:Scarring all along the GI tract resulting in strictures.

8. Treatment If symptomatic, check level If patient is sick, the they should receive deferoxamine Usual indications for deferoxamine are: – Shock – Profound acidosis – Level 500-600 or more

9. Deferoxamine Will make urine red tinged (vin rose) Treatment beyond 24 hours may be associated with the development of ARDS Rapid infusion can produce hypotension.

10. Deferoxamine Dosing: 10-15mg/kg/hr continuous infusion Treat until iron levels decreases to normal range

11. Other modalities Whole Bowel Irrigation In Children, exchange transfusion may be indicated. No role for dialysis. No role for charcoal.