Iron toxicity - Poisoning by Iron Altaf Ansari Beth Israel Medical Center Iron Toxicity 5000 cases of Iron OD per year s 20,000 cases of

Info iconThis preview shows page 1. Sign up to view the full content.

View Full Document Right Arrow Icon
This is the end of the preview. Sign up to access the rest of the document.

Unformatted text preview: Poisoning by Iron Altaf Ansari Beth Israel Medical Center Iron Toxicity 5000 cases of Iron OD per year s 20,000 cases of multivitamin with Iron per 20,000 year year s Pills fruit flavored s Animal shaped s bottles of up to 250 s Vitamins generally not considered toxic s Iron Toxicity s Relative toxicity of Iron depends on the Relative total amount of elemental Iron total Elemental Iron Equivalents Ferrous sulfate (anhydrous) s Ferrous sulfate (hydrated) s Ferrous gluconate s Ferrous fumarate s Ferrous chloride (anhydrous) s Ferrous chloride (hydrated) s Ferrous carbonate s 37% 20% 12% 33% 44% 28% 12% Dose Related Toxicity <20mg/kg non toxic s 20-60mg/kg moderately toxic s >60 mg/kg severely toxic s 180-300 mg/kg lethal s 30-45 tablets in a 10 kg child is lethal s Question 15 years old girl presents to ED s Suicidal gesture. s Ingested 60 tablets of Ferrous sulfate 300mg s C/O hematemesis and bloody diarrhea once s Embarrassed and remorseful now s Wishes to be discharged home with parents s Question s s s s s s s s Vital signs: BP 96/62, BP HR 108/min, HR R 18/min, 18/min, Temp 98.8 R Temp Pulse Ox 98% RA Pain 2/10 Weight 50 Kg Question What to do? s Ipecac orally. Ipecac s Arrange out patient psyche follow up. s Initiate Deferoxamine therapy. s Obtain abdominal radiographs. s Gastric lavage with Sodium bicarbonate. s Answer Ipecac Contra-indicated s Out-patient Psych. Needs in patient ICU s Deferoxamine. s Abdominal radiographs indicated, not Abdominal helpful if all Iron already absorbed. helpful s Gastric lavage with Bicarb. No data to show Gastric benefits benefits s Why Deferoxamine? Ferrous sulfate=20% elemental Iron s Each tablet = 300mg Iron s Each tab = 300mg X 20% = 60mg Each Elemental Iron Elemental s 60 tablets of Ferrous sulfate 300mg each = s 3600mg Elemental Iron s 3600mg/50 Kg = 72 mg/Kg ingested s Toxicity by Peak Serum Iron Level 50-150 mcg/dl s <350 mcg/dl s 350-500 mcg/dl s >500 mcg/dl >500 lethal lethal s normal none to mild toxicity moderately toxic severely toxic to Risk of Coma by Peak Serum Iron Level <500 mcg/dl s 500-1000 mcg/dl s >1000 mcg/dl s 10% 25% 75% Iron Metabolism 15mg ingested daily s 10% of ingested Fe absorbed daily s Increased ingestion=Increased absorption s Iron Metabolism 1 mg of Fe lost daily through GI mucosa, mg bile, skin and urine bile, s 2 mg of Fe maximum is lost daily even with mg Fe overload Fe s 16 mg of Fe menstrual loss per month 16 s 1.5 mg of Fe per day transferred to fetus s Pathophysiology of Fe Toxicity Direct caustic effect on GI mucosa s Direct myocardial depression s Vasodilatation and increased capillary Vasodilatation permeability permeability s Lactic acidosis, disrupts mitochondrial Lactic oxidative phosphorylation oxidative s Catalyzes lipid peroxidation & free radicals s Stage 1 0-6 hours Nausea,vomiting, diarrhea s upper or lower GI bleeding s Abdominal pain, perforation, peritonitis s Hypotension, tachycardia, shock s Hyperglycemia, leucocytosis, metabolic Hyperglycemia, acidosis acidosis s Stage 2 2-48 hours Apparent recovery s GI symptoms subside s False sense of security!!! s Hyperglycemia, leucocytosis, acidosis Hyperglycemia, persist persist s Stage 3 6-48 hours Multiple organ dysfunction syndrome s Cardiovascular collapse s Cerebral edema s Pulmonary edema s Renal failure s Severe metabolic acidosis, leucocytosis, Severe elevated PT elevated s Stage 4 2-6 days Acute Hepatic Failure s Jaundice s Coma s Abnormal LFTs, Elevated PT, Abnormal Hypoglycemia s Stage 5 2-6 weeks GI scarring s Gastric outlet obstruction s Intestinal obstruction s Diagnosis s Diagnosis of Fe poisoning should always Diagnosis be on clinical grounds! be Ancillary lab help leucocytosis s hyperglycemia, later hypoglycemia s metabolic acidosis s abnormal LFTs s Elevated Lactate s KUB before and after lavage s Serum Fe level >350 mcg/dl s ED Diagnosis of Fe poisoning Be persistent about History s Obtain empty bottles and calculate amount Obtain of elemental Fe ingested of s Serum Fe level at presumed 4 hours, and a Serum second level at 6-8 hours (sustained release?) release?) s Serum Fe level may be normal in Sage 3 s Ancillary tests, and KUB s Treatment of Fe Toxicity Consult Poison Control Early!!! s Airway, breathing, circulation s 2 large bore IVs, cardiac & pulse ox large monitors,oxygen monitors,oxygen s Initial labs including Type and Crossmatch s Gastric Emptying Not neccessary if patient vomited and KUB Not negative negative s Pills may clump together s May erode mucosa and get embeded in sub May mucosa mucosa s Fe bezoars may require endoscopy or Fe Gastrotomy Gastrotomy s Fe Binding in GI Tract No activated charcoal (Poor Fe binding) s Gastric lavage with Bicarbonate, Gastric Phosphosoda or Deferoxamine not recommended recommended s Decrease GI Transit time No emetics or cathartics s Whole Bowel Irrigation with Poly ethylene Whole glycol or PEG-EL or Go-Lytely glycol s Given per NGT s 1.5-2.0 liters per hour in adults s 25 ml/kg/hr in children s Continue for 5 hours or until Continue Effluent=Infusate Effluent=Infusate s Chelation Therapy, Deferoxamine Specific Chelator of Ferric Iron s Fe +Deferoxamine=Ferrioxamine s Ferrioxamine excreted in urine s Ferrioxamine also dialyzable s Limits Fe entry into the cell s Also chelates Intracellular Fe s Deferoxamine 100 mg of Deferoxamine binds with 8.5 mg 100 of elemental Fe. of s May be given IM or IV s IV is the preferred method of administration s Deferoxamine Challange Test Give 50 mg/kg IM upto 1 gram s Ferrioxamine gives “vin rose”color to urine s Compare color of urine pre and post Compare Deferoxamine Deferoxamine s If test Positive, start chelation s If test Negative and no symptoms for 6 hrs, If pt.may be discharged pt.may s Deferoxamine Negative Deferoxamine test by itself does Negative not rule out Fe toxicity not s All the Fe may be intracellular by now s Dose: 15 mg/kg/ hour IV until urine returns Dose: to normal color or toxicity disappears to s Indications for Deferoxamine All symptomatic patients with more than 1 All episode of vomiting or diarrhea episode s All patients with abdominal pain, All hypovolemia, acidosis, lethargy hypovolemia, s KUB with multiple opacities s Even asymptomatic patients with SI 300500 mcg/dl s Pregnancy is not a contra-indication s Deferoxamine , Adverse Reactions Anaphlaxis, or anaphylactoid reactions s Hypotension if given too fast s Optic neuropathy, hearing loss s Thrombocytopenia s ARDS if given for >24 hrs s Deferoxamine, Adverse Reactions Acute renal failure s Yersenia Enterocolitis (growth factor) s Mucormycosis, Pneumocystis (T cell Mucormycosis, depression) depression) s Deferoxamine + Compazine = Coma s Severe Iron Toxicity Exchange transfusion s Charcoal hemoperfusion s Hemofiltration s Hemodialysis after Deferoxamine s Free radical Scavengers:vit C, vitE, Free Sulphdryl groups Sulphdryl s Liver transplant s ...
View Full Document

This note was uploaded on 01/11/2012 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

Ask a homework question - tutors are online