Pediatric emergency medicine trisk 3074 3074
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Patients with only mild vomiting and diarrhea in the early postingestion period
still need urgent treatment but usually do well. WBI is the preferred method of GI
decontamination. Draw blood, as above, and begin parenteral deferoxamine
therapy.
If available, send blood for serum iron levels obtain an abdominal radiograph,
monitor the patient for 6 hours. An iron level of less than 350 mcg/dL taken 3 to 5
hours after ingestion in an asymptomatic patient with a normal radiograph
suggests that the patient is at minimal risk and may be discharged. Admission and
continued chelation with deferoxamine are indicated for iron levels higher than
500 mcg/dL, the development of any symptoms, or a positive radiograph.
When serum iron levels are not available on an emergency basis, clinical
decisions must be made based on symptoms, electrolytes, and abdominal
radiography. Observe the patient for 6 hours. Those who have normal screening
tests and remain asymptomatic may be discharged. Patients with abnormal
screening laboratory tests should have an iron level sent for later reference.
Acidotic or symptomatic patients should be admitted and treated with
deferoxamine.
All children alleged to have ingested iron are potentially at significant risk for
life-threatening illness. However, severe iron poisoning is uncommon compared
with the number of children who develop only mild symptoms or remain entirely
asymptomatic. Thus, the emergency physician needs an approach that
encompasses the response to the severely poisoned child and to most who will
remain well.
As noted earlier, the amount of iron ingested is often hard to quantify, and
minimal safe amounts are not well established. Serum iron levels do not correlate
well with the likelihood of developing symptoms (usually a reflection of the
serum iron that exceeds the iron-binding capacity and results in free-circulating
iron). However, when drawn 3 to 5 hours after ingestion, iron levels lower than
350 mcg/dL generally predict an asymptomatic course. Patients with levels in the
350 to 500 mcg/dL range often show mild phase I symptoms but rarely develop
serious complications. Levels higher than 500 mcg/dL suggest significant risk for
phase III manifestations. However, the serum iron determination is not always
available on a stat basis.
Although serum iron levels are useful, toxicity from iron overdose remains a
clinical diagnosis. Ill patients require vigorous hydration and support. Children
who are completely asymptomatic 6 hours after ingestion are unlikely to develop
systemic illness. Among laboratory studies, the presence of metabolic acidosis
probably best correlates with toxicity. Radiopaque material on abdominal
