IRON POISONING

Many OTC preparations contain iron

leading cause of poisoning death in
children
Most common form: ferrous
sulphate,ferrous gluconate & ferrous
fumerate.
Iron tablets normally look like candies, or
animal-shaped & considered quite
harmless
Prenatal multivitamins are the source of
iron in
most lethal ingestion among
children.they are
usually found in homes with young
children.

Pathophysiology of Iron Toxicity

Direct toxic effect on GI mucosa
Direct myocardial depression
Vasodilatation & increased capillary
permeability
Lactic acidosis, disrupts mitochondria
oxidative phosphorylation
Catalyses lipid peroxidation & formation of
free radicals
Interfere with coagulation process

Iron Toxicity
Relative toxicity of iron depends on the total
amount of
elemental iron
Elemental Iron Equivalents
- Ferrous sulphate ( anhydrous )
37%
- Ferrous sulphate ( hydrated )
20%
- Ferrous gluconate
12%
- Ferrous fumarate
33%
- Ferrous chloride ( anhydrous )
44%
- Ferrous chloride ( hydrated )
28%
- Ferrous carbonate
12%

Dose Related Toxicity For Iron

< 20mg/kg
non-toxic
20-60 mg/kg
moderately
toxic
> 60 mg/kg
severely
toxic
180-300 mg/kg
lethal
30-45 tablets in a 10 kg child is lethal

Signs And Symptoms Of Iron Poisoning

Stage

Time Postingestion

Desription

Within 6 hr

Vomiting,hematemesis (vomiting blood),

explosive diarrhoea, irritability, abd
pain & lethargy.If toxicity is
severe,tachycardia,
Tachypnea (rapid breathing),hypotension,
coma & metabolic acidosis

Within 6-48 hr

Latent period, apparent recovery

12-48 hr

Shock, seizure, fever, coagulapathy &

metabolic acidosis

2-5 days

Hepatic failure, jaundice, coagulapathy

& hypoglycemia

2-5 weeks

Gastric outlet & duodenal obstruction

-scarring

Prognosis & Treatment

if no symptoms develop within 1st 6 hr after ingestion, risk of
serious toxicity minimal.
If shock & coma develop within 1st 6 hr, mortality rate is about 10%
If radiopaque tablets are visible on abdominal x-ray, whole bowel
irrigation with polyethylene glycol : 1 to 2 L for adults or 2440ml/kg/h for children is done
Gastric lavage is usually not helpful because vomiting tends to
empty stomach more efficiently
Activated charcoal not used because it will not adsorb iron.
In severe toxicity (metabolic acidosis, shock, severe gastroenteritis
or serum iron level more than 500 mcg/dl ) , IV desferrioxamine
is used to chelate free serum iron.
Desferrioxamine is infused at rates up to 15mg/kg/h IV, titrated
until hypotension occurs.
Both desferrioxamine & iron poisoning can decrease BP, pt
receiving require IV hydration
Urine colour changes to a red-orange in pt treated with
desferrioxamine.

Chelation Therapy
Desferrioxamine

Specific chelator of ferric iron

Fe + Desferrioxamine = Ferrioxamine
Ferrioxamine excreted in the urine
Ferrioxamine also dialyzable
Limits Fe entry into cells
Also chelates intracellular Fe
100mg of Desferrioxamine binds with 8.5mg of
elemental Fe
Maybe given IM or IV ( IV preferred )
Dose : 15mg/kg/hr by continous IV infusion.
Reduced after
4-6 hours. Max 80mg/kg in 24 hr

Indication For Desferrioxamine

All symptomatic pt with more than 1
episode of vomiting or diarrhoea
All pt with abdominal pain, hypovolemia,
acidosis, lethargy
X-ray with multiple opacities
Even asymptomatic pt with serum iron 300
-500mcg/dl
Pregnancy is not a contraindication

Desferrioxamine Challenge Test

Give 50mg/kg IM, up to 1g

Ferrioxamine gives vin-rose colour to urine
Compare colour of urine pre & post desferrioxamine
If test positive, start chelation therapy
If test negative and no symptoms for 6 hours pt
maybe discharged
Negative desferrioxamine test by itself does not
rule out Fe toxicity all the Fe maybe intracellular
by now
Dose : 15mg/kg/hr IV until urine returns to normal
colour or toxicity disappear

Side Effects of Desferrioxamine

(Desferal)
Hypotension with rapid injection
Anaphylatoid reaction with rapid injection
Hypotension associated with
desferrioxamine accumulation in pt with
renal impairment
Fever ,dysuria, leg cramps, rashes &
pruritis
Acute respiratory distress syndrom with
infusion durations more than 24 hrs