1. Hans Li 3032950

2. Let’s look at this case  You are a specialist working at the poisons information centre.  A grandmother who is babysitting a 20 months old boy (AG) called you.  The boy has swallowed a few tablets and started vomiting.

3. A description of the tablets Descriptions of the tablets from the Grandma:  “Small reddish brown tablets”,  “Rounded on each side”,  “A bit shiny with something like very thin Glad Wrap on them”,  “Something looks like a small letter ‘a’ on one side”, ......

4. What is this medicine? Where to find the information??  MIMs online https://www.mimsonline.com.au/Search/Search.aspx https://www.mimsonline.com.au/Search/Search.aspx  AMH

5. “Small reddish brown tablets, rounded on each side, a bit shiny with something like very thin Glad Wrap on them, something looks like a small letter ‘a’ on one side.” Bioglan Hemofactor Centrum Fefol 270 mg/300 mcg Elevit OxiChel Chewable Tablet Ferro-Gradumet 325 mg Ferrograd C 105/500 mg OxiChel Tablets FGF 250 mg

6. Ferro-Gradumet  Composition Dried ferrous sulfate 325 mg (equiv. elemental iron 105 mg) in a controlled release dosage form. Contains lactose. Gluten and sucrose free.  Precautions Do not take this product for more than 12 months except on medical advice.  Dosage and Administration 1 tablet daily or as directed by a doctor.  Presentation Tablets (red, biconvex, film coated, marked with Abbott logo on one side): 30's (bottle).

7. Case cont.  His mother was eventually contacted and the tablets were confirmed as iron tablets she was taking during her recent pregnancy.  AG was sent to Emergency Department within 20 munities by ambulance.

8. How is AG? Patient details & symptoms & signs: Patient name: AGSex: Male Age: 20 months Consciousness: Alert and awakeBody weight: 10kg Body Temp: 37 o CBreaths/min: 28 Heart Rate: 125/minOxygen saturation: 99% Other clinical symptoms: Continuing vomiting

9. Is he OK?  Composition Dried ferrous sulfate 325 mg (equiv. elemental iron 105 mg).  So 105mg * 11 tablets= 1155mg; 1155mg/10kg=115.5mg/kg (Serious toxicity is generally seen at doses of more than 60mg/kg).  He is not OK...

10. Toxic effects of metals METALCNSGILUNGKIDNEYLIVERHEARTBLOODSKIN Aluminium** Copper** Iron***** Lead***** Selenium*** Zinc**

11. The next step- Diagnosis  Primary diagnosis: Iron overdose?  Past medical history: nil  **ALLERGY**: not known  In hospital, even though the data is limited, NO diagnosis, NO treatment.

12. General principles in the approach to the patient with an acute emergency Pulse Rhythm Cardiac monitoring Blood pressure Temperature Mental state Presenting complaint: Focused care

13. Diagnosing treatment  AG soon stopped vomiting and was not in any apparent distress.  Due to unconfirmed initial diagnosis, AG was given a diagnosing treatment: Whole bowel irritation with a polyethylene glycol solution was used for 4 hours until the rectal effluent was clear- no evidence of tablets was seen.

14. Polyethylene glycol laxatives  Mode of action Iso-osmotic solutions containing electrolytes and polyethylene glycol (PEG), which clean the bowel by causing diarrhoea.  Indications Whole bowel irrigation for selected poisonings, including controlled release products, iron, lithium and potassium.

15. Confirmed clinical diagnosis  After the initial treatment, AG did not have any CNS or cardiovascular symptoms. A serum iron concentration (taken 3 hours ago) was 75micromol/L (=4.2mg/L).  Reference range are dependent on sex and age: Men: 0.6-2.2mg/L Women: 0.3-1.9mg/L  Clinical diagnosis: Iron overdose Iron toxicity

16. Case cont.  Short afterwards, he started to become drowsy and irritable, and a second serum iron concentration was ordered (6 hours after). This presentation persisted for several hours, with some vomiting. The second serum iron concentration was reported as 95micromol/L (=5.32mg/L).  A serum iron concentration above 5mg/L on initial presentation is an indication of potentially serious toxicity. METALCNSGILUNGKIDNEYLIVERHEARTBLOODSKIN Aluminium** Copper** Iron***** Lead***** Selenium*** Zinc**

17. Further clinical intervention Desferrioxamine therapy was begun at 8mg/kg/hour, increasing every 5 minutes to 15mg/kg/hour.

18. Desferrioxamine - A chelating agent  Mode of action: Removes metals, in particular iron and aluminium, from the systemic circulation, by forming water-soluble complexes that are excreted in the urine.  Indications: Acute : Peak serum iron concentration (occurs 3–6 hours after ingestion) >90 micromol/L OR Significant symptoms of iron toxicity (GI haemorrhage, acidosis, sedation, hypotension) and serum iron concentration >60 micromol/L.  Dose: Adult, child, IV infusion 15 mg/kg/hour until serum iron concentration is <60 micromol/L.

19. Prognosis  AD was transferred to the paediatric ICU for continuing treatment for the next 13 hours. His vomiting stopped and his behaviour returned to normal. Serum iron concentration was reported as 15 micromol/L (= 0.84mg/L)- NORMAL!! (Men: 0.6-2.2mg/L).  He was discharged from hospital after another day of observation.

20. Other possible treatments Dialysis treatment? Perform Dialysis Dialysis is a last-resort effort to keep the patient stabilized after iron poisoning. It replaces the function of the kidneys by processing and removing extra iron from the body.

21. Therapy window Clear history and clinical symptoms and signs Clinical experience Early stage intervention— Reduced toxicity & Better prognosis There might be a chance we give the Desferrioxamine therapy as the initial treatment...

22. Take-home Principles  Therapy window  No diagnosis, No treatment  Keep medicines out of children’s touch  The principles in Emergency Department  Normal iron concentration: Men: 0.6-2.2mg/L Women: 0.3-1.9mg/L  A good baby-sitter?

23. Reference:  (1) Boyle JS. Pediatric Iron Toxicity Treatment & Management. 2009; Available at: http://emedicine.medscape.com/article/1011689-treatment. Accessed 4 April, 2011. http://emedicine.medscape.com/article/1011689-treatment  (2) eMIMS. Pill Identifier Search-Iron. 2011; Available at: https://www.mimsonline.com.au/Search/ImageSearchResult.aspx?ModuleName=Pill%20ID&searc hKeyword=iron. Accessed 4 April, 2011. https://www.mimsonline.com.au/Search/ImageSearchResult.aspx?ModuleName=Pill%20ID&searc hKeyword=iron  (3) Humes HD. General Principles in the Approach to the patient with an acute Emergency. Kelley's Textbook of Internal Medicine. 4th ed. USA: Lippincott Williams & Wilkins; 2000. p. 324-335.  (4) Jickells S, Negrusz A. Introduction to forensic toxicology. Clarke's Analytical Forensic Toxicology. 1st ed. USA: the Pharmaceutical Press; 2008. p. 1-11.  (5) Kellerman G. Haematology Tests. Abnormal Laboratory Results. 2nd ed. NSW Australia: Mc Graw Hill; 2001. p. 267-421.  (6) Klaassen CD. Toxic effect of metals. Casarett & Doull's Toxicology: The basic science of poisons. 7th ed. USA: Mc Graw Hill; 2008. p. 883-930.  (7) Rossi S. Antidotes and antivenoms. Australian Medicines Handbook. 2010th ed. Adelaide SA: Pharmaceutical Society of Australia; 2010. p. 60-81.  (8) Timbrell J. Introduction. Introduction to Toxicology. 3rd ed. Florida USA: CRC; 2002. p. 1-17.  (9) Watkins JB. General Principles of Toxicology. Casarett & Doull's essentials of Toxicology. 1st ed. New York USA: Mc Graw Hill; 2003. p. 3-46.

24. Thank you for listening