What is the appropriate management for a pediatric patient with acute iron poisoning?

Management of Acute Iron Overdose in a 12-Year-Old Child

The immediate management for this 12-year-old boy who consumed 20 iron tablets (1200 mg elemental iron) should include gastrointestinal decontamination, supportive care, and administration of deferoxamine as the specific antidote.

Initial Assessment and Stabilization

• Assess and stabilize airway, breathing, and circulation as the first priority 1
• Calculate the ingested dose: 20 tablets × 60 mg elemental iron = 1200 mg total; with an estimated weight of 40 kg for a 12-year-old boy, this equals approximately 30 mg/kg of elemental iron 2
• This dose exceeds the potentially toxic threshold of 20-40 mg/kg, requiring aggressive intervention 3

Gastrointestinal Decontamination

• Perform gastric lavage if the patient presents within 1-2 hours of ingestion 3
• Consider whole bowel irrigation with polyethylene glycol-electrolyte solution, especially if radiopaque pills are visible on abdominal X-ray 3
• Do not administer activated charcoal as it does not bind iron effectively 4

Laboratory Assessment

• Obtain immediate serum iron levels, complete blood count, comprehensive metabolic panel, and coagulation studies 4
• Check arterial blood gases if the patient shows signs of metabolic acidosis 5
• Consider abdominal X-ray to identify radiopaque iron tablets in the gastrointestinal tract 3

Deferoxamine Administration

• For this pediatric patient with significant iron ingestion (30 mg/kg), deferoxamine therapy is indicated 1

• If the patient is not in shock:

  • Administer deferoxamine intramuscularly at an initial dose of 1000 mg, followed by 500 mg every 4 hours for two doses 1
  • Additional doses of 500 mg may be given every 4-12 hours based on clinical response 1
  • Total daily dose should not exceed 6000 mg in 24 hours 1

• If the patient develops cardiovascular collapse:

  • Switch to intravenous administration at a rate not exceeding 15 mg/kg/hour for the first 1000 mg 1
  • Subsequent IV dosing must not exceed 125 mg/hour 1
  • Discontinue IV administration as soon as the patient's condition stabilizes, and switch to intramuscular route 1

Monitoring and Supportive Care

• Monitor vital signs, mental status, and urine output continuously 4
• Provide fluid resuscitation if signs of hypovolemia develop 5
• Correct metabolic acidosis if present 5
• Monitor for signs of hepatotoxicity, which may develop 12-48 hours after ingestion 6

Consideration for Hemodialysis

• Consider hemodialysis in cases of severe toxicity with persistent metabolic acidosis, deteriorating clinical status despite deferoxamine therapy, or extremely high serum iron levels (>1000 μg/dL) 5
• Hemodialysis can assist in decreasing serum iron concentration and improving clinical status in patients with life-threatening toxicity 5

Clinical Course and Prognosis

• Iron poisoning typically progresses through five clinical phases: gastrointestinal toxicity, relative stability, circulatory shock and acidosis, hepatotoxicity, and gastrointestinal scarring 6
• Early recognition and treatment with deferoxamine significantly improves outcomes and prevents progression to later, more severe phases 7

Follow-up Care

• Continue monitoring liver function tests for at least 48-72 hours after ingestion 4
• Psychiatric evaluation may be warranted if ingestion was intentional 4