Daily bolus of LR: Iron toxicity

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February 7, 2011 by dailybolusoflr

The five classic stages of iron toxicity are:
1.       GI  (Usually starts about 6 hours after ingestion; nausea and diarrhea; severe may be hemorrhagic)
2.       Stable without symptoms (LATENT 6-12 hours)
3.       Shock and acidosis (In severe cases can start as early as 6 hours; most patients who will die do so during this phase; AMS, heart/kidney failure)
4.       Hepatotoxicity (LFTs and bilirubin may elevate with co-existent coagulopathy)
5.       GI scarring (delayed; often weeks after the ingestions; may lead to significant pathology such as gastric outlet obstruction or intestinal obstruction)
Individuals demonstrate signs of GI toxicity after ingestion of more than 20 mg/kg.
Moderate toxicity occurs when ingestion of elemental iron exceeds 40 mg/kg.
Ingestions exceeding 60 mg/kg can cause severe toxicity and may be lethal.
A level at around 4 hours typically represents steady state.  Levels earlier or later may misrepresent true  levels.  Hydration is a key initial therapy.  Chelation is the standard of care.  It is indicated for serum iron levels >350 mcg/dL with evidence of toxicity or >500 mcg/dL regardless of signs or symptoms.
NOTE: Activated charcoal does not significantly bind iron and whole bower irrigation is the standard decontamination method for iron overdose.
Linda Regan, MD FACEP
Program Director, Emergency Medicine Residency
Johns Hopkins Medical Institutions

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