A 30 month old female is brought to the emergency department by her 16 year old babysitter.  Her babysitter states the patient was vomiting in the living room of her (the patient’s) home.  When asked about her story further, she admits that she had left the patient alone in the living room, and that saw some pill fragments in the patients’ vomit.  She couldn’t remember the color or shape of the pills.  She didn’t want to get in trouble for leaving the patient unattended, so she did not bring the patient in right after it happened (it has since been about 5 hours). She reports the patient’s parents are out somewhere, and they are not answering their cell phones.  She lives with her mother, father, and 2 week old baby brother.

Her vital signs in triage are:

T = 98.6, BP = 90/66, HR = 136, RR = 20, O2 = 99% room air

Fingerstick = 120

You are obviously concerned about an ingestion (also consider infection, CNS disorders, metabolic derangements, trauma).  To start you get a blood gas, CBC, and basic metabolic panel.  She rushes back with the results:

pH = 7.26

pO2 = 34

pCO2 = 88

HCO3 = 19

lactate = 8

Na = 142, K =  4.0, Cl = 99, HCO3 = 19, BUN = 15, Cr = 0.4, glucose = 121, calcium = 9

So our patient has…

Anion gap metabolic acidosis.

Old school: MUDPILES ~ methanol, uremia, DKA, propylene glycol/paraldehyde, infection/iron/INH/in born errors of metabolism, lactic acidosis, ethylene glycol, salicyclates

New school: KULT – ketones, uremia, lactate, toxic alcohols

 

In the case of the above patient, she was found to have an elevated iron level, 550.  As it turns out, the patient had gotten into a container of prenatal vitamins her mother had been taking prior to giving birth to her baby brother.  Her LFTs were normal.  She was admitted to the PICU for further observation and for treatment with IV deferoxamine.

 

Background:

Iron toxicity is derived from the concentration of elemental iron ingested – ferrous gluconate (12% elemental iron), sulfonate (20% elemental iron), or fumarate (33% elemental iron).

Prenatal vitamins typically have 65 mg of elemental iron

Multivitamin typically have 15 mg of elemental iron.

Iron pills (included in OCP regimens) typically have 25 mg of elemental iron.

Iron levels should be drawn within 4-6 hours of ingestion.

Clinically insignificant toxicity/no treatment: < 20 mg/kg

Serious symptoms: > 60 mg/kg

Toxicity:

Phase I – abdominal pain, vomiting/hematemesis, bloody diarrhea, melena, fever, lethargy.  Occurs 30 min to 12 hours after ingestion.

Phase II – latent period 8-36 hours after ingestion, plan to monitor > 36 hours

Phase III – systemic toxicity – liver injury or failure, hypoglycemia, metabolic acisis, coma, seizure, etc.  Occurs 12-48 hours after ingestion.

Phase IV – recovery/intestinal, pyloric, and antral stenosis, cirrhosis

Treatment:

Asymptomatic at 6 hours and negative abdominal x-ray -> home

Deferoxamine – given if: the patient is in shock, metabolic acidosis, AMS, persistent GI symptoms, serum iron level > 500, dose > 60 mg/kg, pills on imaging; 15 mg/kg/hr IV -> urine will turn vin rose color

Side effects of deferixamine are hypotension, diarrhea, tachycardia, ARDS, erythema

 

References:

 

https://pedclerk.bsd.uchicago.edu/sites/pedclerk.uchicago.edu/files/uploads/1-s2.0-S0045938000800560-main.pdf

 

http://www.calpoison.org/hcp/2003/callusvol1no3.html