1. Introduction

• Iron is widely available in prenatal vitamins, daily supplements, and multivitamins.
• Pediatric poisonings are usually accidental (tablets resemble candy).
• Adult poisonings are often suicidal.

2. Common Iron Formulations

• Ferrous sulfate → 20% elemental iron
• Ferrous gluconate → 12% elemental iron
• Ferrous fumarate → 33% elemental iron
• Carbonyl iron / Iron polysaccharide complex → Less toxic than salts

3. Toxic Dose

• < 20 mg/kg → Unlikely to cause symptoms
• 20–30 mg/kg → Mild, self-limiting GI symptoms
• > 40 mg/kg → Serious toxicity possible
• > 60 mg/kg → Potentially lethal

4. Mechanism of Toxicity

1. Direct corrosive effect → Hemorrhagic necrosis, GI perforation, massive fluid loss → hypovolemia & shock.
2. Cellular toxicity → Free iron exceeds binding capacity → oxidative stress, lactic acidosis, mitochondrial dysfunction, multi-organ failure.

5. Clinical Stages

1. GI Phase (0.5–6 hrs): Vomiting, diarrhea (bloody), abdominal pain, hematemesis, massive fluid loss → shock.
   غياب الأعراض خلال أول 6 ساعات يستبعد التسمم الشديد.
2. Latent Phase (6–24 hrs): Apparent improvement, but ongoing cellular toxicity → tachycardia, lethargy, metabolic acidosis.
3. Systemic Toxicity (6–72 hrs): Shock, seizures, coma, metabolic acidosis, coagulopathy. Risk of Yersinia enterocolitica sepsis (especially if treated with deferoxamine).
4. Hepatic Failure (2–4 days): Coagulopathy, hepatic necrosis, possible ARDS.
5. Late Complications (2–8 weeks): GI strictures, pyloric stenosis, bowel obstruction.

6. Investigations

• Serum iron level (best at 4–6 hrs post ingestion):
  • < 300 mcg/dL → unlikely serious toxicity
  • 300–500 mcg/dL → GI symptoms
  • 500–1000 mcg/dL → systemic toxicity
  • > 1000 mcg/dL → severe, high mortality

• Other labs: CBC, electrolytes, ABG, LFTs, coagulation profile, renal function, glucose, lactate.
• Abdominal X-ray: Radiopaque tablets visible in many cases.

7. Management

A. Stabilization

• Secure airway, breathing, circulation.
• Aggressive IV crystalloids for hypovolemic shock.
• Blood transfusion if needed.
• Vasopressors if shock persists.
• Treat seizures, coma, metabolic acidosis.

B. Decontamination

• Activated charcoal → NOT effective for iron (only if co-ingestion).
• Whole Bowel Irrigation (WBI):
  • 30 mL/kg/hr via NG tube until clear effluent.
  • Indicated if X-ray shows tablets, or in symptomatic patients.
• Gastric lavage: Limited role, not routinely recommended.

C. Antidote – Deferoxamine (Desferrioxamine)

• Indications:
  • Serum iron > 500 mcg/dL (≈ > 90 µmol/L)
  • Severe symptoms: shock, acidosis (pH < 7.1), altered consciousness.
• Dose: 15 mg/kg/hr IV infusion (max 6 g/day; do not exceed 80 mg/kg/24 hrs).
• Monitor urine for vin rosé (orange/pink) color (ferrioxamine complex).
• Stop when: patient improves, acidosis resolves, serum iron < 500 mcg/dL.
• ⚠ Prolonged use > 24–48 hrs may cause ARDS or Yersinia sepsis.

D. Enhanced Elimination

• Hemodialysis does not remove iron, but can remove ferrioxamine in renal failure.
• Exchange transfusion: occasionally in children, but not routine.

E. Supportive Care

• Volume resuscitation = key (hypovolemia is the main early killer).
• Correct metabolic acidosis, coagulopathy, hypoglycemia.

8. Prognosis

• Mild cases → resolve within 12–48 hrs.
• Severe cases → may progress to multi-organ failure.
• Mortality < 1% without shock/ coma, but up to 50% if shock/ coma untreated.
• Late GI strictures may appear after 4–8 weeks.

9. Discharge Criteria

• Observation ≥ 6 hrs post ingestion AND all:
  • No vomiting
  • Ingestion < 20 mg/kg
  • Serum iron < 300 mcg/dL at 4–6 hrs
• All suicidal ingestions → psychiatric evaluation.

Summary in Arabic (الخلاصة)

• الحديد سام بجرعة > 40 مج/كجم، وقاتل > 60 مج/كجم.
• أخطر المراحل: الصدمة + الفشل الكبدي + المضاعفات المتأخرة (انسداد).
• التشخيص يعتمد على مستوى الحديد في الدم + الأشعة.
• العلاج: إنعاش + غسيل أمعاء + ديفيروكسامين IV عند الحالات الخطيرة.