The preferred method of GI decontamination is whole bowel irrigation (WBI).6 Activated charcoal does not adsorb iron. WBI with polyethylene glycol electrolyte lavage solution (PEG-ELS) should be initiated if pills are seen on abdominal radiographs. PEG-ELS is given by nasogastric tube at a rate of 25 mL/kg/h in small children and 1 to 2 L/h in adolescents and adults. The end point of therapy is a clear rectal effluent. It is also useful to obtain a postirrigation abdominal x-ray to confirm the absence of pills. Active gastrointestinal bleeding, ileus, and bowel obstruction are contraindications to WBI.6
Even moderately poisoned children require meticulous supportive care to ensure a positive outcome. For patients in shock, large volumes of IV fluids and sodium bicarbonate are required to maintain fluid, electrolyte, and acid–base status.
Chelation with intravenous deferoxamine is used for significant iron ingestions. Indications are the presence of significant symptoms or signs of iron poisoning, a serum iron concentration greater than 500 μg/dL or metabolic acidosis.
Deferoxamine should be administered at a rate of 15 mg/kg/h. Administration of intravenous deferoxamine to patients with intravascular volume deficits risks nephrotoxicity. It is important to provide a bolus of crystalloid before initiating the deferoxamine infusion. The duration of chelation therapy is variable; there are no reliable end points.7 Serum iron determinations during the course of iron poisoning do not reflect clinical toxicity, and they are often unreliable during deferoxamine therapy.
Using a return of urine color to normal is not recommended as an end point for chelation therapy. It has never been validated, and pigmentation of urine (vin rose urine) is concentration and pH dependent. The most useful criterion for continued chelation is the presence of a metabolic acidosis despite satisfactory perfusion. This indicates the presence of non–transferrin-bound iron in the plasma. Deferoxamine is rarely required beyond the initial 24 hours after iron ingestion.
Hypotension is a potential side effect of intravenous deferoxamine therapy if it is given too rapidly. In a dog model, hypotension has been observed at infusion rates of 100 mg/kg/h. It is not reported at the usually recommended rate in humans, 15 mg/kg/h. Delayed pulmonary toxicity with symptoms resembling those of acute respiratory distress syndrome has been reported in patients who received prolonged chelation (>24 hours).8
Renal failure can be seen in ill hypovolemic patients. For patients undergoing chronic therapy, visual and hearing deficits and Yersinia infections have been reported.