1. Group 2 (213-224) Day: Sunday Time:10-12 - Lab :A Date:6-3-2016

2.  a-22-year old pregnant female weighing 65kg was transferred to the emergency department 5hours after ingesting iron containing prenatal vitamins. The patient suffered from intense bouts of brown, sandy emesis with blood, abdominal pain and she was lethargic. Investigation revealed that the patient ingested 70 tablets containing ferrous sulfate. Anhar safwat 213 Ethar Ibrahim 217

3.  Physical examination: › B.P 80/50 › R.R 35/min.  Lab tests: › High level of lactic acid › Serum iron 36omcg/dl  X-ray examination › X-ray shows the presence of tablets in the stomach.  Anhar safwat 213 Ethar Ibrahim 217

4.  Was this a toxic dose? › Tablets containing ferrous sulfate  70 *325=22750 mg  22750*(20/100)=4550 mg  4550/65=70 mg/kg It’s in the range of severe toxicity ( >60 mg/kg to 180 mg/kg ) Olivia Emad 214 Ereny saad 218

5.  Explain the reasons of her physical examination ?  1- low B.P ( 80/50) - normal B.P is (120/80)  a)decreased blood vol. due to the intense bouts of bloody emesis  b)GIT tissue damage cause release of ferritin- ( is an intracellular protein that stores iron and releases it in a controlled fashion) – so this Iron has direct arteriolar VD & increase capillary permeability, which is followed by reflex tachycardia. Eman Ahmed 222 Eman Gamal 224

6.  2-R.R 35/min ( tachypnea to remove xss CO2 )  Due to acidosis : xss H + +Hco3 H2co3 H2O+CO2 Pass BBB & medullary respiratory center & increase RR. Eman Ahmed 222 Eman Gamal 224

7.  What is the cause of elevated lactic acid? 1) hypotension which led to hypoperfusion led to hypoxemia. 2) uncoupling of oxidative phosphorylation leads to low ATP production. Elaria Emil 220 Eriny mamdouh 219

8.  What is the management?  Pregnancy shouldn't delay or preclude therapy when an iron over dose is suspected.  fears of potential teratogenicity shouldn't interrupt initiation of such treatment, as fetal safety is dependent on maternal health. Ayat Ahmed 215 Ayat Mohamed 216

9. 1) Hypotension treatment : patient should be placed in Trendlenburg position. Giving 1-2 liter of 0,9% NaCl saline vasopressor agent as dopamine 2-5 mcg/kg/min. * If no response, giving nor-epinephrine 0,1-0,2 mcg/kg/min. Ayat Ahmed 215 Ayat Mohamed 216

10. 2)Gastric Decontamination :  Gastric lavage is considered using a large-bore orogastric tube with NaHCo3 to form the insoluble FeCo3 salt and decrease iron absorption. Ayat Ahmed 215 Ayat Mohamed 216

11. 3)Antidote (Chelation ) : Deferoxamine : Chelating agent that exhibits high affinity & specificity for iron forms the soluble complex ferrioxamine that eliminated by the kidney. Used when presence of lethargy, hypotension and iron serum is > 350. The end point of antidote therapy is determined by the disappearance of vin rose color in urine. Ayat Ahmed 215 Ayat Mohamed 216

12.  International journal of clinical medicine http://dx.doi.org/10.4236/ijcm.2012.37A126