Managing Acute Iron Poisoning in the ED: Rusty Disaster

-Case-

A frantic mother rushes into the ED with her 3-year-old son who was found next to an open bottle of his grandmother’s iron supplements. She’s not sure how many he swallowed, but she estimates “a handful.” The patient looks pale and lethargic, with intermittent vomiting. His vital signs show tachycardia and mild hypotension.

Regardless of the medication, a patient presenting as such after an ingestion is concerning! Fortunately for us, we know exactly what this child swallowed, so we can swoop quickly into action!  

-Evaluation-

Iron poisoning is a life-threatening overdose, most commonly seen in young children who ingest adult iron supplements. Toxicity occurs in five distinct phases:

• Phase 1 (0-6 hours): GI symptoms
• Phase 2 (6-24 hours): “Latent” phase
• Phase 3 (6-72 hours): Systemic toxicity (metabolic acidosis, shock, hepatotoxicity, coagulopathy)
• Phase 4 (12-96 hours): Hepatic failure, multi-organ dysfunction
• Phase 5 (weeks later): Gastric outlet obstruction from scarring

Diagnosis:

• Serum iron levels (measured at 4-6 hours post-ingestion) → concern for a toxic ingestion if iron levels exceed 350 mcg/dL
• ABG: look for metabolic acidosis with elevated anion gap
• KUB (abdominal x-ray): may show iron tablets if radiopaque

-Management-

1. Supportive Care; IV fluids for hypovolemia, anti-emetics for vomiting, monitor glucose (iron poisoning can cause hyperglycemia)
2. GI Decontamination:
   • Whole bowel irrigation for significant ingestions if tablets are visible on x-ray
   • Activated charcoal is ineffective
3. Antidote:
   • Deferoxamine (IV chelation therapy) indicated with severe symptoms, metabolic acidosis, iron >500 mcg/dL, or signs of shock
4. ICU admission for severe cases, such as hemodynamic instability, persistent acidosis, or multi-organ failure

– Fast Facts-

• Iron toxicity follows a predictable, five-phase timeline
• No GI symptoms ≠ reassurance; symptoms may temporarily improve before worsening!
• No activated charcoal! It doesn’t bind iron; however, deferoxamine is life-saving in severe cases
• KUB can help but doesn’t rule out toxicity

Iron poisoning is an under-recognized but deadly ingestion, particularly in children. Early recognition, aggressive supportive care, and timely chelation therapy are crucial!

Want to learn more? Read our in-depth study guide and listen to our podcast episode on this topic!

Cheers,

Tamir Zitelny, MD