INTRODUCTION Although iron poisoning is the most common cause of death due to poisoning in young children, it is also a significant problem in adolescents and adults.

pharmacokinetic Total body iron = 3-5gr Ferrous =70%, myoglobin and hemoglobin ferric =25%, ferritin and hemosiderin Transferrin and enzymes =5% Absorption duodenom proximal jejunum

Amount of elemental iron in tablets  Sufate 300/325mg 20%  Fumarate 200mg 33%  Gluconate 300mg 12%  Mulitivitamins :  Children’s chwable 4_18mg/tab  Adult 6_50mg/tab  Prenatal 36_65mg/tab

Pathophysiology Iron is potent catalyst of free radical formation and is capable of oxidizing a wide range of substrates,including lipid, protein,DNA, and various biomolecules. Typical iron poisoning targets:  GI  CVS  Liver  CNS  Hematopoietic system  Metabolic acidosis

 GI:abdominal pain,vomiting,bleeding,intestinal Infarcts  CVS:hypotension,low cardiac out put,cardiomyopathy,Hypovolemia,hypoperfusion  Liver:hepatic necrosis,hypoglycemic,encephalopathy, Coagulopathy  Hematopoietic system :coagulopathy  CNS:lethargic,coma,seizure  Metabolic acidosis

Clinical presentation  Stage1-GI (0.5-6h):abdominal pain,vomiting,darrhea, Hematemesis,hematochezia,melena  Stage 2-relative stability(4-12h):GI symptoms improve,subclinical hypoperfusion  Stage 3-shock and acidosis(6-72h):hypoperfusion, metabolic acidosis,coma,coagulopathy,ARDS, potential multisystem failure  Stage 4-hepatic necrosis(12-96h):coma,coagulopathy, Jaundice  Stage 5-bowel obstruction(2-4w):abdominal pain,vomiting,dehydration

Diagnosis  clinical  History  physical exam  laboratory: 1-abdominal radiograph,2-serum iron concentration,3- ABG,CBC,BS,BUN,Cr,Coagulation profiles,LFT,electrolytes,crossmatch  Differential diagnosis: consider metabolic, structural,infectious and other poisoning with GI symptoms

Iron toxicity  No symptoms for 6h =No toxicity  <300 microgram/dl No toxicity  mild  >500 severe  <20mg/kg only vomiting and nausea  >60mg/kg toxic

Treatment  1.stabilize patient as needed  2.estimate risk for systemic toxicity by amount of elemental iron  3.IV access  4.laboratory exam  5.GI decontamination:whole bowel irrigation if tablets are seen on radiograph(PEG 2lit/h in adult,1lit/h in children)  6.chelation

Chelation  Iron antidote = Deferoxamine (DFO) = a growth factor found in the streptomyces pilosus  Mechanis :Fe binding, vinrose(challeng test)  Indications:serum fe>500, notable clinical symptoms(coma, hypovolemia,coagulopathy,metabolic acidosis),many tablets at radiograph,remain symptoms fe)  Dose: 15mg/kg/h infusion for no longer than 24h and max 30 mg/kg/h

 Criteria for stopping therapy: improving symptoms,Fe<150mic/dl,lack of tablets, normal urine color  Side effects: hypotension,rash,sepsis,ARDS(>24h)

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