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tox.iron-overdose.core.v1PRODUCTION
tox.iron-overdose.core.v1

Iron overdose

toxicologyacutepediatricadult
Hard-required inputs
0 / 12
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm acute iron poisoning scope; stage-based not level-only; flag pediatric exploratory vs intentional adult ingestion

Inputs
3
Actions
0
Advance rule
Set
Advance when

Acute iron ingestion confirmed; elemental-iron mg/kg band estimated; lethal scenario flagged

Patient inputs (18)

Pediatric exploratory ingestion is the classic lethal scenario; deferoxamine dosing is mg/kg

Toxicity stratified by ELEMENTAL iron mg/kg; deferoxamine 15 mg/kg/h infusion is weight-based

Risk band: <20 minimal, 20–40 mild GI, 40–60 moderate, >60 potentially lethal (drives decontamination + chelation threshold)

Ferrous sulfate 20%, fumarate 33%, gluconate 12% elemental — converts product mg to elemental iron mg/kg

Five-stage time-course; GI symptom absence at 6 h essentially excludes significant toxicity; serum iron peaks 4–6 h

Peak level: >500 µg/dL serious, >1000 severe — but clinical stage, not level alone, drives chelation; sustained-release/late may need repeat

Stage 3 anion-gap lactic acidosis; severe metabolic acidosis is a life-threatening trigger + chelation indication

Anion-gap lactic acidosis from mitochondrial toxicity / shock; severity marker

High-anion-gap metabolic acidosis is a toxic marker and differential pivot vs salicylate/toxic alcohols

Stage 1 marker and the single best clinical predictor; presence/absence at 6 h is decisive

Stage 3 hypovolemic/distributive/cardiogenic shock — life-threatening trigger

AMS/lethargy/coma is a systemic-toxicity red flag and chelation indication

Sustained-release/enteric-coated → delayed/prolonged absorption; repeat iron level + extended observation

Glucose >150 mg/dL is a classic toxic marker (Lacouture criteria) in pediatric ingestion

WBC >15,000 is a classic toxic marker (Lacouture criteria) predicting serum iron >300 µg/dL

Stage 4 centrilobular hepatic necrosis — second leading cause of death; coagulopathy is a red flag

Radio-opaque tablets confirm ingestion + guide whole-bowel irrigation; chewable/liquid often invisible — negative film does NOT exclude

Hemodialysis does NOT remove iron but clears ferrioxamine (deferoxamine-iron complex) in renal failure

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningshock_or_severe_metabolic_acidosis
    Hypotension / distributive-hypovolemic-cardiogenic shock OR severe anion-gap metabolic acidosis (stage 3) — AACT/EAPCCT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningserum_iron_over_1000_or_500_with_symptoms
    Serum iron >1000 µg/dL (severe) OR >500 µg/dL with clinical symptoms — AACT/EAPCCT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningstage4_hepatic_failure
    Rising transaminases / INR / hypoglycemia / encephalopathy 12–96 h post-ingestion — centrilobular necrosis (second leading cause of death) — critical-care tox review 2024-2025
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningams_or_coagulopathy
    Altered mental status / coma OR coagulopathy with active bleeding — AACT/EAPCCT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresignificant_clinical_toxicity_regardless_of_level
    Significant clinical toxicity (persistent vomiting/hematemesis, AMS, acidosis) regardless of serum iron level — AACT/EAPCCT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremassive_radio_opaque_burden
    Large radio-opaque tablet burden / pill mass on abdominal radiograph or massive elemental ingestion (>60 mg/kg) — Manoguerra/AAPCC triage guideline
    Trigger could not be auto-evaluated — needs clinician judgement.

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RED_FLAGSrequiredDrives severity classification
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Recommended regimen

Iron poisoning — staged management (resuscitate → decontaminate → chelate → support → late strictures)
axis: iron_overdose_staged_managementstep 1 - Step 1 — Resuscitation + correct acidosis / coagulopathy
Selected step "Step 1 — Resuscitation + correct acidosis / coagulopathy" — Any symptomatic ingestion, GI losses, hypotension, or stage-3 shock / metabolic acidosis
  • isotonic_crystalloid_resuscitation
    first line
    iv_fluid_resuscitation
    20 mL/kg boluses (peds) / 1–2 L (adult), titrate to perfusion • IV • repeat to endpoint
    triggers: hypotension, gi_volume_loss, stage3_shock
    AACT/EAPCCT — iron causes hypovolemic + distributive + cardiogenic shock; aggressive volume is the resuscitative cornerstone
  • sodium_bicarbonate
    add on
    alkalinizing_agent
    1–2 mEq/kg IV bolus then infusion titrated to pH • IV • titrated
    triggers: severe_metabolic_acidosis, ph_under_7_1
    Correct severe anion-gap lactic acidosis driving cellular toxicity (adjunct to perfusion restoration, not a substitute)
    rxcui 36676
  • fresh_frozen_plasma_vitamin_k
    rescue
    coagulopathy_correction
    FFP 10–15 mL/kg ± vitamin K 5–10 mg • IV • guided by INR / bleeding
    triggers: coagulopathy, active_bleeding, hepatic_stage4
    Iron-induced coagulopathy (early direct effect + later hepatic synthetic failure) — correct for active bleeding/procedure

ed playbook — drug actions (4)

  1. 1. isotonic_crystalloid_resuscitation
    20 mL/kg peds boluses / 1–2 L adult • IV • titrate to perfusion
    trigger: Hypotension, GI volume loss, or symptomatic ingestion
    Resuscitative cornerstone — hypovolemic/distributive/cardiogenic shock
  2. 2. whole_bowel_irrigation_polyethylene_glycol
    PEG 1.5–2 L/h adult / 25–40 mL/kg/h peds • PO/NG • until effluent clear & KUB clears
    trigger: Radio-opaque tablets / large solid ferrous ingestion
    Charcoal does NOT bind iron — WBI is the decontamination of choice
  3. 3. sodium_bicarbonate
    1–2 mEq/kg IV then titrated infusion • IV • titrated to pH
    trigger: Severe anion-gap metabolic acidosis
    Adjunct to perfusion restoration for severe acidosis
  4. 4. deferoxamine
    15 mg/kg/h IV infusion, titrate • IV • continuous
    trigger: Systemic toxicity / shock / severe acidosis / iron >500 with symptoms / significant clinical toxicity
    Chelation antidote — clinical stage drives the decision, not level alone

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Reported ingestion of iron / ferrous salt / prenatal-multivitamin; Child found with open prenatal/adult ferrous bottle (classic lethal scenario); Elevated serum iron level (4–6 h post-ingestion peak).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Iron overdose** (tox.iron-overdose.core.v1).
Phenotype framing: Distinguish from salicylate OD (mixed acid-base + tinnitus), toxic alcohols (osmolar gap), acetaminophen OD (delayed hepatotoxicity, level-nomogram), septic gastroenteritis, other AGMA causes
Scope: Confirm acute iron poisoning scope; stage-based not level-only; flag pediatric exploratory vs intentional adult ingestion

No severity triggers fired against current inputs.

Plan

Regimen axis: **Iron poisoning — staged management (resuscitate → decontaminate → chelate → support → late strictures)** — step "Step 1 — Resuscitation + correct acidosis / coagulopathy".
1. isotonic_crystalloid_resuscitation 20 mL/kg boluses (peds) / 1–2 L (adult), titrate to perfusion IV repeat to endpoint (iv_fluid_resuscitation, first line) — AACT/EAPCCT — iron causes hypovolemic + distributive + cardiogenic shock; aggressive volume is the resuscitative cornerstone
2. sodium_bicarbonate 1–2 mEq/kg IV bolus then infusion titrated to pH IV titrated (alkalinizing_agent, add on) — Correct severe anion-gap lactic acidosis driving cellular toxicity (adjunct to perfusion restoration, not a substitute)
3. fresh_frozen_plasma_vitamin_k FFP 10–15 mL/kg ± vitamin K 5–10 mg IV guided by INR / bleeding (coagulopathy_correction, rescue) — Iron-induced coagulopathy (early direct effect + later hepatic synthetic failure) — correct for active bleeding/procedure

Setting playbook (ed) — Estimate elemental-iron mg/kg, risk-stratify by GI symptoms + 4–6 h iron level + KUB, resuscitate, start WBI for radio-opaque burden, begin deferoxamine for systemic toxicity
4. isotonic_crystalloid_resuscitation 20 mL/kg peds boluses / 1–2 L adult IV titrate to perfusion — Hypotension, GI volume loss, or symptomatic ingestion (Resuscitative cornerstone — hypovolemic/distributive/cardiogenic shock)
5. whole_bowel_irrigation_polyethylene_glycol PEG 1.5–2 L/h adult / 25–40 mL/kg/h peds PO/NG until effluent clear & KUB clears — Radio-opaque tablets / large solid ferrous ingestion (Charcoal does NOT bind iron — WBI is the decontamination of choice)
6. sodium_bicarbonate 1–2 mEq/kg IV then titrated infusion IV titrated to pH — Severe anion-gap metabolic acidosis (Adjunct to perfusion restoration for severe acidosis)
7. deferoxamine 15 mg/kg/h IV infusion, titrate IV continuous — Systemic toxicity / shock / severe acidosis / iron >500 with symptoms / significant clinical toxicity (Chelation antidote — clinical stage drives the decision, not level alone)

Non-pharmacologic actions:
- IV access × 2 large-bore; cardiac + SpO2 monitoring — Manoguerra/AAPCC triage guideline
- Do NOT give activated charcoal (does not bind iron) — AACT/EAPCCT
- Engage regional poison center / medical toxicology early — Manoguerra/AAPCC triage guideline
- Psychiatric evaluation if intentional — critical-care tox review 2024-2025
- Child-protection / safety review if pediatric exploratory ingestion — Manoguerra/AAPCC triage guideline

AVOID / contraindication checks:
- Activated_charcoal_does_NOT_bind_iron_not_useful — AACT/EAPCCT position statement
- Deferoxamine_avoid_prolonged_infusion_gt_24h_ARDS_risk — critical care tox review 2024 2025
- Deferoxamine_rapid_infusion_causes_hypotension_titrate — AACT/EAPCCT
- Deferoxamine_increases_Yersinia_enterocolitica_sepsis_risk — critical care tox review 2024 2025
- Negative_abdominal_radiograph_does_NOT_exclude_iron_toxicity_chewable_liquid_radiolucent — Manoguerra/AAPCC triage guideline
- Serum_iron_level_not_sole_driver_clinical_stage_matters_repeat_for_sustained_release — AACT/EAPCCT

Monitoring

Regimen monitoring:
- serial serum iron q2 4h until falling and for sustained release — AACT/EAPCCT
- ABG lactate anion gap q2 4h during acute phase — critical-care tox review 2024-2025
- LFT INR coags q12h for stage4 hepatic necrosis — critical-care tox review 2024-2025
- renal function q12h especially during deferoxamine — AACT/EAPCCT
- urine colour for vin rose ferrioxamine excretion — AACT/EAPCCT
- deferoxamine infusion duration track to avoid gt 24h ARDS — critical-care tox review 2024-2025
- hemodynamics continuous for stage3 shock — Manoguerra/AAPCC triage guideline

Setting (ed) monitoring:
- Serum iron / ABG / lactate / anion gap q2–4h initially — AACT/EAPCCT
- CBC, CMP/LFT, coags at baseline then per stage — critical-care tox review 2024-2025
- Repeat KUB after WBI to confirm tablet clearance — Manoguerra/AAPCC triage guideline
- Urine colour (vin rosé = ferrioxamine) once deferoxamine running — AACT/EAPCCT

Follow-up plan: 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
- Close-out criterion: Stricture surveillance + safety/education plan documented

Monitoring phase: Serial iron/ABG/lactate/anion gap, LFT/coags/renal, urine colour ("vin rosé" = ferrioxamine excretion), deferoxamine infusion duration (ARDS risk if >24 h), hemodynamics

Disposition

Current setting: ed — Estimate elemental-iron mg/kg, risk-stratify by GI symptoms + 4–6 h iron level + KUB, resuscitate, start WBI for radio-opaque burden, begin deferoxamine for systemic toxicity

Disposition criteria:
- Discharge home: asymptomatic at 6 h with non-toxic dose (<20–40 mg/kg elemental) AND normal labs AND clear/negative-relevant KUB AND no co-ingestants AND psych cleared — Manoguerra/AAPCC triage guideline
- Admit ward/observation: mild GI symptoms, non-toxic level, no acidosis, sustained-release needing extended observation — AACT/EAPCCT
- Admit ICU: shock, severe acidosis, AMS, level >500 with symptoms / >1000, hepatic stage 4, on deferoxamine — critical-care tox review 2024-2025
- Transfer: chelation/ICU capability or transplant centre if irreversible hepatic failure — critical-care tox review 2024-2025

Escalation triggers (move to higher acuity):
- Hypotension / shock → ICU + aggressive resuscitation + deferoxamine — critical-care tox review 2024-2025
- Severe metabolic acidosis (pH <7.1 or refractory) → ICU + deferoxamine — AACT/EAPCCT
- AMS / coma / seizure → ICU + airway protection — critical-care tox review 2024-2025
- Serum iron >1000 µg/dL OR >500 with symptoms → ICU + deferoxamine — AACT/EAPCCT
- Rising transaminases / INR (stage 4) → ICU + ALF pathway — critical-care tox review 2024-2025

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Hypotension / distributive-hypovolemic-cardiogenic shock OR severe anion-gap metabolic acidosis (stage 3) — AACT/EAPCCT
- [LIFE_THREATENING] Serum iron >1000 µg/dL (severe) OR >500 µg/dL with clinical symptoms — AACT/EAPCCT
- [LIFE_THREATENING] Rising transaminases / INR / hypoglycemia / encephalopathy 12–96 h post-ingestion — centrilobular necrosis (second leading cause of death) — critical-care tox review 2024-2025

Citations

- AACT/EAPCCT position statements (whole-bowel irrigation; single-dose activated charcoal) + 2024-2025 critical-care toxicology reviews + Manoguerra/AAPCC iron ingestion out-of-hospital triage guideline [PMID:15363042](https://pubmed.ncbi.nlm.nih.gov/15363042/)
- Cited evidence (PMID 25224489) [PMID:25224489](https://pubmed.ncbi.nlm.nih.gov/25224489/)
- Cited evidence (PMID 16035484) [PMID:16035484](https://pubmed.ncbi.nlm.nih.gov/16035484/)
- Cited evidence (PMID 10382554) [PMID:10382554](https://pubmed.ncbi.nlm.nih.gov/10382554/)
- Cited evidence (PMID 8035314) [PMID:8035314](https://pubmed.ncbi.nlm.nih.gov/8035314/)

Last reconciled with current guidelines: 2026-05-16.
References
  • AACT/EAPCCT position statements (whole-bowel irrigation; single-dose activated charcoal) + 2024-2025 critical-care toxicology reviews + Manoguerra/AAPCC iron ingestion out-of-hospital triage guideline — PMID:15363042
  • Cited evidence (PMID 25224489) — PMID:25224489
  • Cited evidence (PMID 16035484) — PMID:16035484
  • Cited evidence (PMID 10382554) — PMID:10382554
  • Cited evidence (PMID 8035314) — PMID:8035314