Pediatric emergency medicine trisk 3078 3078
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or “sludge,” as long as there is no evidence of peritonitis or perforation. In
patients with considerable initial radiographic findings, particularly pill
concretions, a follow-up radiograph should be obtained to assess the adequacy of
bowel cleansing. Further options of gastroscopy or even gastrotomy are reserved
as last resorts to effect iron pill removal. For example, large clumps of coalesced
iron tablets in the stomach or duodenum have led to severe hemorrhagic
infarction of these viscera with subsequent perforation, peritonitis, and death. As
previously noted, even in such patients who survive the acute phase, there is
considerable risk of subsequent pyloric or bowel stenosis with obstruction,
usually 4 to 6 weeks after ingestion. In this regard, we also urge early pediatric
surgical consultation for patients in the first few days after ingestion who show
any evidence of peritoneal irritation.
Chelation therapy with parenteral deferoxamine enhances the excretion of iron
as the ferrioxamine complex, which turns urine an orange or vin rose tint. The
most efficacious route is a continuous IV infusion, and the maximum
recommended dose is 15 mg/kg/hr (maximum daily dose 360 mg/kg, up to 6 g
total). A higher infusion rate has been associated with hypotension but may be
necessary (in conjunction with blood pressure support) for severe ingestions.
Chelation is continued until the serum iron level returns to normal, metabolic
acidosis has resolved, the patient is clinically improved, and the urine color
returns to normal. The dose of deferoxamine may be titrated down in concert with
the patient’s clinical response and fall in iron levels. Of note, deferoxamine is
considered to be a siderophore that promotes the growth of certain bacteria such
as Yersinia enterocolitica; therefore, monitoring for Yersinia sepsis is important.
Once the patient has been stabilized initially, further problems may include
hypotension, profound metabolic acidosis, hypoglycemia or hyperglycemia,
anemia, and colloid loss caused by GI hemorrhage (after equilibration), renal
shutdown resulting from shock, and hepatic failure with an associated bleeding
diathesis. The maintenance of an adequate urine output is critical to prevent renal
failure and to foster excretion of the ferrioxamine complex. If renal failure
supervenes, chelation may be continued with concurrent dialysis because the
complex is dialyzable.
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