What is the treatment for a suspected iron overdose in a child or individual with a history of mental health disorders or substance abuse?

Treatment of Acute Iron Overdose

Acute iron overdose requires immediate gastrointestinal decontamination and intravenous deferoxamine chelation therapy, with the route and intensity of treatment determined by the severity of toxicity and presence of shock. 1, 2

Immediate Assessment and Risk Stratification

The severity of iron poisoning must be rapidly assessed based on:

• Elemental iron dose ingested: Ingestions >60 mg/kg are potentially serious and warrant aggressive intervention 2
• Clinical manifestations: Gastrointestinal symptoms (vomiting, diarrhea, abdominal pain), altered mental status, shock, metabolic acidosis 3, 2
• Serum iron concentration: Levels >500 mcg/dL indicate significant toxicity; levels >1,000 mcg/dL are associated with severe systemic toxicity 2, 4
• Radiographic evidence: Abdominal X-ray may reveal radiopaque iron tablets in the GI tract 2

Gastrointestinal Decontamination

Gastric lavage should be performed immediately in patients presenting within 1-2 hours of ingestion, using a solution containing deferoxamine and sodium bicarbonate. 2 This approach serves dual purposes: mechanical removal of tablets and local chelation of iron in the stomach.

• Whole-bowel irrigation with polyethylene glycol-electrolyte solution is indicated when radiographs demonstrate iron concretions or multiple tablets in the small bowel 2
• Continue irrigation until rectal effluent is clear and follow-up radiographs show clearance of tablets 2
• Syrup of ipecac for emesis induction may be considered in the immediate post-ingestion period as an adjunct 1

Deferoxamine Chelation Therapy

Route Selection Based on Clinical Status

For patients NOT in shock (hemodynamically stable):

• Intramuscular administration is preferred 1
• Initial dose: 1,000 mg IM, followed by 500 mg every 4 hours for two doses 1
• Subsequent doses of 500 mg may be given every 4-12 hours based on clinical response 1
• Maximum total dose: 6,000 mg in 24 hours 1

For patients IN SHOCK or with cardiovascular collapse:

• Intravenous administration is mandatory 1, 3
• Initial dose: 1,000 mg IV at a rate NOT exceeding 15 mg/kg/hr 1
• Followed by 500 mg over 4 hours for two doses 1
• Subsequent doses of 500 mg over 4-12 hours as needed 1
• Critical safety parameter: After the first 1,000 mg, infusion rate must not exceed 125 mg/hr 1
• Maximum total dose: 6,000 mg in 24 hours 1

Severe Intoxication Protocol

In cases of massive overdose with life-threatening toxicity (serum iron >2,000 mcg/dL, severe acidosis, coma):

• Continuous IV deferoxamine infusion for 48 hours or until serum iron normalizes 3, 2
• Monitor for characteristic "vin rosé" (rose-colored) urine indicating ferrioxamine excretion 4
• Transition to intramuscular administration once cardiovascular stability is achieved 1

Adjunctive Therapies

Hemodialysis

Hemodialysis should be initiated in patients with massive overdose (>100 mg/kg), severe metabolic acidosis, or serum iron >2,000 mcg/dL despite deferoxamine therapy. 3 Hemodialysis can rapidly decrease serum iron concentration and improve clinical status when conventional chelation is insufficient 3.

Supportive Care Measures

• Fluid resuscitation: Aggressive IV fluids to maintain intravascular volume and treat shock 4
• Acidosis correction: Sodium bicarbonate for severe metabolic acidosis 2, 4
• Blood product replacement: Packed red blood cells for gastrointestinal hemorrhage from necrotizing gastroenteritis 2
• Coagulation disorder management: Fresh frozen plasma or other blood components as indicated 4

Monitoring Parameters

Throughout treatment, serial monitoring must include:

• Serum iron levels: Every 4-8 hours until declining and <350 mcg/dL 3, 2
• Complete blood count: Monitor for leukocytosis (marker of severity) and anemia from GI bleeding 2
• Metabolic panel: Assess for hyperglycemia (early marker), acidosis, and electrolyte disturbances 2
• Liver function tests: Aminotransferases, bilirubin, and coagulation studies to detect hepatotoxicity 5
• Renal function: Creatinine and urine output, as acute kidney injury may occur 6

Special Considerations for High-Risk Populations

Patients with Mental Health Disorders or Substance Abuse History

These patients require:

• Psychiatric evaluation and continuous observation to prevent repeat ingestion 5, 6
• Lower threshold for ICU admission given intentional overdose typically involves larger quantities 6
• Consideration of liver transplant evaluation early if acute liver failure develops, as intentional overdoses in adolescents can result in fulminant hepatic failure requiring transplantation 6

Critical Pitfalls to Avoid

• Do not delay deferoxamine waiting for serum iron results if clinical toxicity is evident (shock, severe GI symptoms, altered mental status) 2, 4
• Do not use oral deferoxamine for systemic chelation; it is only effective as a lavage solution 2
• Do not exceed maximum infusion rates for IV deferoxamine, as rapid infusion can cause hypotension and acute respiratory distress 1
• Do not discontinue therapy prematurely; continue until serum iron normalizes and clinical improvement is sustained 3, 2
• Do not miss late hepatotoxicity; liver injury can develop 24-48 hours post-ingestion even with initially lower serum iron levels 5

Surgical Intervention

Surgical removal of iron tablets via gastrotomy is indicated only when:

• Massive numbers of tablets form gastric concretions visible on imaging 4
• Conservative measures (lavage, whole-bowel irrigation) fail to clear tablets 4
• Progressive clinical deterioration occurs despite maximal medical therapy 4