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tox.iron-overdose.core.v1

Iron overdose

toxicologyacutepediatricadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest path is a PLACEHOLDER pointing at tox.acetaminophen-overdose.core.v1.ts — no tox.iron-overdose manifest authored yet; replace once authored (tracked in brief Open gaps). No problem-package folder / atoms split files for iron overdose; design brief at src/lib/dossiers/_briefs/tox.iron-overdose.core.v1.md is the only on-disk authored artifact beyond this dossier. Regimen axis intentionally carries NO rxcui — deferoxamine / sodium bicarbonate / PEG RxNav validation deferred to Stage-A API pass (see brief). Procedural/decontamination/imaging entries marked non_pharm:true. Calculator surface limited to whitelisted calc.qsofa (systemic-toxicity/shock screen) + calc.news2 (deterioration track); no iron-specific severity calculator exists in clinical-tools-registry.ts. workup.iron_overdose / workup.acute_liver_failure / workup.toxic_alcohols and panels (metabolic/abg/cbc/renal/lft/coag/tox_screen) + cascade.acid_base are the whitelisted registry refs; verify adapter_ids before PRODUCTION. Bayesian likelihood ratios for stage/toxic-marker pretest probability deferred — see brief Open gaps.

Entry points (5)

  • symptom
    Reported ingestion of iron / ferrous salt / prenatal-multivitamin
    iron_ingestion_history
  • symptom
    Child found with open prenatal/adult ferrous bottle (classic lethal scenario)
    pediatric_exploratory_ingestion
  • lab_abnormality
    Elevated serum iron level (4–6 h post-ingestion peak)
    serum_iron_elevated
  • imaging
    Radio-opaque tablets / pill mass on abdominal radiograph
    radio_opaque_tablets_on_kub
  • symptom
    Intentional overdose / suicide attempt with iron-containing product
    intentional_overdose

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    Pediatric exploratory ingestion is the classic lethal scenario; deferoxamine dosing is mg/kg
  • weight_kgrequired
    demographic • used at CONTEXT
    Toxicity stratified by ELEMENTAL iron mg/kg; deferoxamine 15 mg/kg/h infusion is weight-based
  • elemental_iron_dose_mg_kgrequired
    history • used at CONTEXT
    Risk band: <20 minimal, 20–40 mild GI, 40–60 moderate, >60 potentially lethal (drives decontamination + chelation threshold)
  • iron_salt_formulationrequired
    history • used at CONTEXT
    Ferrous sulfate 20%, fumarate 33%, gluconate 12% elemental — converts product mg to elemental iron mg/kg
  • time_since_ingestion_hoursrequired
    history • used at CONTEXT
    Five-stage time-course; GI symptom absence at 6 h essentially excludes significant toxicity; serum iron peaks 4–6 h
  • gi_symptoms_vomiting_diarrhea_hematemesisrequired
    symptom • used at RED_FLAGS
    Stage 1 marker and the single best clinical predictor; presence/absence at 6 h is decisive
  • sbprequired
    vital • used at RED_FLAGS
    Stage 3 hypovolemic/distributive/cardiogenic shock — life-threatening trigger
  • mental_statusrequired
    symptom • used at RED_FLAGS
    AMS/lethargy/coma is a systemic-toxicity red flag and chelation indication
  • serum_iron_4_6hrequired
    lab • used at INITIAL_WORKUP
    Peak level: >500 µg/dL serious, >1000 severe — but clinical stage, not level alone, drives chelation; sustained-release/late may need repeat
  • venous_or_arterial_phrequired
    lab • used at INITIAL_WORKUP
    Stage 3 anion-gap lactic acidosis; severe metabolic acidosis is a life-threatening trigger + chelation indication
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Anion-gap lactic acidosis from mitochondrial toxicity / shock; severity marker
  • anion_gaprequired
    lab • used at INITIAL_WORKUP
    High-anion-gap metabolic acidosis is a toxic marker and differential pivot vs salicylate/toxic alcohols
  • glucose
    lab • used at INITIAL_WORKUP
    Glucose >150 mg/dL is a classic toxic marker (Lacouture criteria) in pediatric ingestion
  • wbc
    lab • used at INITIAL_WORKUP
    WBC >15,000 is a classic toxic marker (Lacouture criteria) predicting serum iron >300 µg/dL
  • lft_inr
    lab • used at INITIAL_WORKUP
    Stage 4 centrilobular hepatic necrosis — second leading cause of death; coagulopathy is a red flag
  • abdominal_radiograph
    imaging • used at INITIAL_WORKUP
    Radio-opaque tablets confirm ingestion + guide whole-bowel irrigation; chewable/liquid often invisible — negative film does NOT exclude
  • sustained_release_preparation
    history • used at CONTEXT
    Sustained-release/enteric-coated → delayed/prolonged absorption; repeat iron level + extended observation
  • renal_function
    history • used at RISK_STRATIFICATION
    Hemodialysis does NOT remove iron but clears ferrioxamine (deferoxamine-iron complex) in renal failure

12-phase flow (12)

  1. 1FRAME
    Confirm acute iron poisoning scope; stage-based not level-only; flag pediatric exploratory vs intentional adult ingestion
    inputs: age, time_since_ingestion_hours, elemental_iron_dose_mg_kg
    advance: Acute iron ingestion confirmed; elemental-iron mg/kg band estimated; lethal scenario flagged
  2. 2ENTRY
    Document ingestion history, product (ferrous sulfate/fumarate/gluconate, prenatal multivitamin), pill count, intent, formulation (sustained-release)
    inputs: iron_salt_formulation, sustained_release_preparation
    advance: Product identified; elemental-iron dose converted from salt formulation; intent captured
  3. 3CONTEXT
    Capture weight (mg/kg dosing), age band, baseline renal/hepatic function, co-ingestants, pregnancy (prenatal-vitamin source)
    inputs: weight_kg, renal_function
    advance: Weight-based risk + chelation dosing context documented
  4. 4RED_FLAGS
    Screen for shock, severe metabolic acidosis, AMS/coma, coagulopathy, hematemesis/melena, level >500–1000 µg/dL, hepatic failure, massive radio-opaque burden
    inputs: gi_symptoms_vomiting_diarrhea_hematemesis, sbp, mental_status
    actions: calc.qsofa
    advance: Red flags acted on; systemic-toxicity / shock / acidosis escalation triggered
  5. 5INITIAL_WORKUP
    Serum iron 4–6 h post (peak), ABG/lactate/anion gap, glucose, CBC, CMP/LFT/renal, coags, type & screen, abdominal radiograph for radio-opaque tablets
    inputs: serum_iron_4_6h, venous_or_arterial_ph, lactate, anion_gap, glucose, wbc, abdominal_radiograph
    actions: workup.iron_overdose, panel.metabolic, panel.abg, panel.cbc, panel.renal, panel.lft, panel.coag, cascade.acid_base
    advance: Peak iron level resolved (4–6 h or repeated for SR), acid-base + KUB returned
  6. 6BRANCHING_WORKUP
    Asymptomatic + non-toxic dose + 6 h GI-free → low risk; symptomatic/toxic → ICU pathway; large radio-opaque burden → whole-bowel irrigation; refractory bezoar → endoscopy/surgery; AGMA differential workup
    inputs: gi_symptoms_vomiting_diarrhea_hematemesis, serum_iron_4_6h, abdominal_radiograph
    actions: workup.toxic_alcohols, workup.acute_liver_failure, cascade.acid_base
    advance: Risk branch selected (low-risk discharge candidate vs toxic ICU pathway vs decontamination-heavy)
  7. 7DIFFERENTIAL
    Distinguish from salicylate OD (mixed acid-base + tinnitus), toxic alcohols (osmolar gap), acetaminophen OD (delayed hepatotoxicity, level-nomogram), septic gastroenteritis, other AGMA causes
    inputs: anion_gap, gi_symptoms_vomiting_diarrhea_hematemesis
    actions: workup.toxic_alcohols
    advance: Iron confirmed as primary; co-ingestants excluded or co-managed
  8. 8RISK_STRATIFICATION
    Stage assignment (1–5); toxic markers (WBC >15k, glucose >150, AGMA, vomiting, radio-opacities); level >500 (serious) / >1000 (severe); qSOFA/NEWS2 for systemic toxicity
    inputs: serum_iron_4_6h, venous_or_arterial_ph, lactate, lft_inr, renal_function
    actions: calc.qsofa, calc.news2
    advance: Iron stage + severity + chelation indication + disposition tier documented
  9. 9TREATMENT
    Aggressive IV crystalloid + correct acidosis/coagulopathy; abdominal film + whole-bowel irrigation with PEG (charcoal does NOT bind iron); endoscopy/surgery for adherent bezoar; deferoxamine IV 15 mg/kg/h for systemic toxicity / level >500 with symptoms; supportive hepatic/renal; HD only for ferrioxamine in renal failure
    inputs: weight_kg, serum_iron_4_6h, venous_or_arterial_ph
    advance: Resuscitation + decontamination + deferoxamine (if indicated) in flight; supportive care active
  10. 10DISPOSITION
    Asymptomatic at 6 h with non-toxic dose + normal labs → discharge (psych clearance if intentional); symptomatic/toxic/chelated → ICU + toxicology/poison-center; late stricture surveillance
    inputs: gi_symptoms_vomiting_diarrhea_hematemesis, serum_iron_4_6h
    advance: Disposition assigned (discharge / ward / ICU / transfer); poison center engaged
  11. 11MONITORING
    Serial iron/ABG/lactate/anion gap, LFT/coags/renal, urine colour ("vin rosé" = ferrioxamine excretion), deferoxamine infusion duration (ARDS risk if >24 h), hemodynamics
    inputs: serum_iron_4_6h, venous_or_arterial_ph, lactate, lft_inr
    actions: panel.metabolic, panel.abg, panel.lft, panel.coag, panel.renal
    advance: Clinical + biochemical improvement; deferoxamine stopped per endpoint; acidosis cleared
  12. 12FOLLOWUP
    Late (2–8 wk) gastric-outlet/bowel-obstruction surveillance for strictures/scarring; GI follow-up; psychiatry safety plan if intentional; poison-prevention education + child-protection if pediatric
    advance: Stricture surveillance + safety/education plan documented