CURRENT Essentials of Critical Care.pdf

232 Current Essentials of Critical Care■■■Iron OverdoseEssentials of Diagnosis• GI symptoms 2 hours; abdominal pain, vomiting, diarrhea, hematemesis,hematochezia; few symptoms seen 6–24 hourspostingestion• Shock, coma, coagulopathy, acidosis, multisystem organ failuremay occur after 6–72 hours; most deaths occur during this phase• Hepatic necrosis occurs within 48 hours of ingestion with orwithout shock; second most common cause of death• Late complications: bowel obstruction at 2–4 weeks• Iron overdose during pregnancy associated with spontaneousabortion, preterm delivery, maternal death• Serum iron level drawn 4–6 hours postingestion 500 g/dLsignificant; prognosis worsens with level 1000 g/dL; levelsdrawn 6 hours postingestion not useful• Iron tablets seen on abdominal radiographs verify ingestionDifferential Diagnosis• Other causes of acute abdominal pain or GI bleedingTreatment• Gastric lavage with large-bore tube followed by whole-bowelirrigation, particularly if tablets seen on abdominal radiograph• Chelation therapy for severe abdominal symptoms, altered mentalstatus, evidence of systemic hypoperfusion, or serum ironlevel 500 g/dL• Chelation with intravenous deferoxamine, usually 15 mg/kg/h;stop when symptoms resolved, serum iron level 150 g/dL,metabolic acidosis gone, urine color returns to normal• Deferoxamine should only be given after intravascular volumedeficits corrected to avoid acute renal failure; IV deferoxamineadministration 24–48 hours may precipitate acute respiratorydistress syndrome• Evaluation for liver transplantation if acute hepatic necrosis■ PearlIf GI symptoms do not occur within 6 hours of ingestion, iron ingestionwas likely nontoxic unless the patient ingested enteric-coated iron.ReferenceTran T et al: Intentional iron overdose in pregnancy—management and outcome.J Emerg Med 2000;18:225. [PMID: 10699527]