CLINICAL
Iron
ASSESSMENT
Poisoning
Assessment of
Radiography in Diagnosis and Management
W.Ng, M.D., C.M., FRCP(C), David J. Martin, M.B., MRCP, FRCP(C)
Raymond C.
Kitty Perry, R.T.,
Severe acute iron poisoning developed in a 1½-year-old child who had eaten iron preparation that resembles a popular chocolate candy. Tablets conof taining iron, with and without vitamins, and the sugar-coatedincandy vitro. Times of with human were juice gastric radiographed appearance, dissolution of the radiopaque tablets were noted, to assess the value of abin the diagnosis and management of acute iron poisoning. dominal
an
similar
radiographs
AcU1°E
vomited Moody material (not regained for examination) and passed a large, black, semitormed stoo). On iris arriva! at the lrt>cal hospital, further vomiting~F~>irrit~.r~ was induced with syrup of ipecac. The contained 47 intact or partially digested tablets. Plain radiograph of the abdomen repeated approxiinately 15 iron tabtets in the upper Gttract(Fig.~!). tntt’avenous infusion of one-third tioriii~il saiine and t~~~c>-t~iir~s glucose was started: 400 mg of
IRON INGESTION is common The widespread use of iron children. among for pregnant women, the addipreparations tion of iron to vitamins as a &dquo;tonic&dquo; for children, the puMic’s’attitude that iron preparations may not be dangerous, and the similar appearance of tablets containing iron compounds, candy-flavored tablets containing vitamins-and-iron, and sugar-coated chocolate candy are all factors allowing accessibility of the toddler to potentially toxic doses of iron.
Case
’
deferoxamine
Report
’At, 9:00 am., two brothers, ages 3% and I V,2 years, wei~e found to have.ingested’ approximately ’ 97 ~~~3~~~~~ ~~b~et~ of ferrous sulfate, The were taken to the local hospital. On arrival there, at 10:00 a.m., the older brother vomited after being given was ~~~r~a~atc>t~ati~3 h~ in the syrup ci~‘ ipecac. No tablets .were detected vomitus or on a plain radiograph, of the abdomen, but the child was transferred to the Hospital for ’
Sick Children. On, arrival here, he was still asympto.matte;
:.
~a~t~i~ lavage was performed’ with half-strength draw ; Flject enelrxa and 5% :NaHC03.~.B&sd:was; for typing and crossn-iatching, and transfusion with : fresh frozen ptasma and NAHCO~ was started iiiimediateiv. >4 central ;enou.s pressure line was in-
~:
complete blood c€U:.-ceun.t, electrolytes and
and total iron-binding capacit,%7 (TIBC) was : The boy was ~ater that dav.
Shortly
after 9:’00~-a.m.,Th€
sertedi and .an I.V. 1,,ifus;*oii of deferox,-lniine, at
y>ounger brother
10
From the Departments of Paediatrics and Radiology. The Hospital for Sick Children, Toronto, Canada. HosCorrespondence to: Dr. Raymond C. W. Ng, The pital for Sick Children, 555 University Avenue, Toronto,
:
Qf bodyweight per h,our,
was begun. The
child’s condition improved steadily. ..’By 6:30 p.ny., the serum iron value had fallen to 435: ug/di. A shortly after plain abdomii-tal radiograph takenmaterial in the mMntght/revcafed.~no.~radtQpa’qMe
inf’usiol’l ~~.~tr~c~irt~~~i~~l ~t~ac~. ~‘~~ r~~~‘~r~~~r~ri~e iron the serum later, ~’c~tar was discontinued. ~~r=s was 61 Agldl. The child, t~~~c~r~~r~e~ without
Ontario, Canada M5G 1X8 Received for publicationMarch 17, 1979; revised May
8, 1979 and accepted June 4. 1979.
administered intramusctuar!y:
t680~gMt~.and~TIBG 32.5,~d!/..Hemat.o}ogic findings, including ;pr6thrombm...ttrne’ and. partial ~; ..&dquo;/... ~ thTombop!astin’t!mewereBnormaL-
~~t~t~~ ~~~~~ ~~r~ ~~r~a~x ~~r~ ~ ~r~r~ c~a~ ~ ~~ ~~I~I~ 346
;
was
and the child was transferred to the Hospitat for Sick Children. On arrival here. at 11:00 am., the child was unconscious; his skiii was cool and slightly niottlet-1, blood pressure was 80/0 mm Hg, and ~ul~e rate was 120 per minute. Phsma iron content (stat testBlood pH, ’7.t1‘~t PC02-55, ing) was >600~gML and HCO,,,-, 14’mEq/!iter; base excess, - 19. Blood urea nitrogen, was 20 mg/dI, and Mood glucose 300 mg/di..Scrum Na, K and Ci were 141, 2.8 and 109 mEq/titer, respectively; serum aspartate aminotransferase (SGOT~’&dquo;~2&dquo;’U/:iteT. Serum iroti was :
;
.~~~r~~~~~ti~~rxs.
&dquo;
614 Downloaded from cpj.sagepub.com at OAKLAND UNIV on June 8, 2015
,..~ ~.~:~...~ ~-/ ~ ~ ’’~/:’ ~..::~,
B
thick (to stimulate the soft tissues of the anterior aspect of the abdomen), and radiographed (74 kvp, 300 r3a:~. for OT 1 sec). The tubes were replaced in ; rack and the htm was developed immediately. This procedure was repeated every 30 minutes until no tablets were visible. B: The experiment was carried out as before except that the tubes were agitated by had for I minute every !5 minutes to simulate to some extent the effect of gastric cm
motility. As shown iia Figure 2, tablets with the highelemental iron content (Numbers 2, 7 and 8) took longest to dissolve. est
Discussion
~~‘a~;.! ~. ~~£ti~t r°~ic~ic>~t’ra~>~~ ct#’tlt~
Iron
ASSESSMENT
Poisoning
Assessment of
Radiography in Diagnosis and Management
W.Ng, M.D., C.M., FRCP(C), David J. Martin, M.B., MRCP, FRCP(C)
Raymond C.
Kitty Perry, R.T.,
Severe acute iron poisoning developed in a 1½-year-old child who had eaten iron preparation that resembles a popular chocolate candy. Tablets conof taining iron, with and without vitamins, and the sugar-coatedincandy vitro. Times of with human were juice gastric radiographed appearance, dissolution of the radiopaque tablets were noted, to assess the value of abin the diagnosis and management of acute iron poisoning. dominal
an
similar
radiographs
AcU1°E
vomited Moody material (not regained for examination) and passed a large, black, semitormed stoo). On iris arriva! at the lrt>cal hospital, further vomiting~F~>irrit~.r~ was induced with syrup of ipecac. The contained 47 intact or partially digested tablets. Plain radiograph of the abdomen repeated approxiinately 15 iron tabtets in the upper Gttract(Fig.~!). tntt’avenous infusion of one-third tioriii~il saiine and t~~~c>-t~iir~s glucose was started: 400 mg of
IRON INGESTION is common The widespread use of iron children. among for pregnant women, the addipreparations tion of iron to vitamins as a &dquo;tonic&dquo; for children, the puMic’s’attitude that iron preparations may not be dangerous, and the similar appearance of tablets containing iron compounds, candy-flavored tablets containing vitamins-and-iron, and sugar-coated chocolate candy are all factors allowing accessibility of the toddler to potentially toxic doses of iron.
Case
’
deferoxamine
Report
’At, 9:00 am., two brothers, ages 3% and I V,2 years, wei~e found to have.ingested’ approximately ’ 97 ~~~3~~~~~ ~~b~et~ of ferrous sulfate, The were taken to the local hospital. On arrival there, at 10:00 a.m., the older brother vomited after being given was ~~~r~a~atc>t~ati~3 h~ in the syrup ci~‘ ipecac. No tablets .were detected vomitus or on a plain radiograph, of the abdomen, but the child was transferred to the Hospital for ’
Sick Children. On, arrival here, he was still asympto.matte;
:.
~a~t~i~ lavage was performed’ with half-strength draw ; Flject enelrxa and 5% :NaHC03.~.B&sd:was; for typing and crossn-iatching, and transfusion with : fresh frozen ptasma and NAHCO~ was started iiiimediateiv. >4 central ;enou.s pressure line was in-
~:
complete blood c€U:.-ceun.t, electrolytes and
and total iron-binding capacit,%7 (TIBC) was : The boy was ~ater that dav.
Shortly
after 9:’00~-a.m.,Th€
sertedi and .an I.V. 1,,ifus;*oii of deferox,-lniine, at
y>ounger brother
10
From the Departments of Paediatrics and Radiology. The Hospital for Sick Children, Toronto, Canada. HosCorrespondence to: Dr. Raymond C. W. Ng, The pital for Sick Children, 555 University Avenue, Toronto,
:
Qf bodyweight per h,our,
was begun. The
child’s condition improved steadily. ..’By 6:30 p.ny., the serum iron value had fallen to 435: ug/di. A shortly after plain abdomii-tal radiograph takenmaterial in the mMntght/revcafed.~no.~radtQpa’qMe
inf’usiol’l ~~.~tr~c~irt~~~i~~l ~t~ac~. ~‘~~ r~~~‘~r~~~r~ri~e iron the serum later, ~’c~tar was discontinued. ~~r=s was 61 Agldl. The child, t~~~c~r~~r~e~ without
Ontario, Canada M5G 1X8 Received for publicationMarch 17, 1979; revised May
8, 1979 and accepted June 4. 1979.
administered intramusctuar!y:
t680~gMt~.and~TIBG 32.5,~d!/..Hemat.o}ogic findings, including ;pr6thrombm...ttrne’ and. partial ~; ..&dquo;/... ~ thTombop!astin’t!mewereBnormaL-
~~t~t~~ ~~~~~ ~~r~ ~~r~a~x ~~r~ ~ ~r~r~ c~a~ ~ ~~ ~~I~I~ 346
;
was
and the child was transferred to the Hospitat for Sick Children. On arrival here. at 11:00 am., the child was unconscious; his skiii was cool and slightly niottlet-1, blood pressure was 80/0 mm Hg, and ~ul~e rate was 120 per minute. Phsma iron content (stat testBlood pH, ’7.t1‘~t PC02-55, ing) was >600~gML and HCO,,,-, 14’mEq/!iter; base excess, - 19. Blood urea nitrogen, was 20 mg/dI, and Mood glucose 300 mg/di..Scrum Na, K and Ci were 141, 2.8 and 109 mEq/titer, respectively; serum aspartate aminotransferase (SGOT~’&dquo;~2&dquo;’U/:iteT. Serum iroti was :
;
.~~~r~~~~~ti~~rxs.
&dquo;
614 Downloaded from cpj.sagepub.com at OAKLAND UNIV on June 8, 2015
,..~ ~.~:~...~ ~-/ ~ ~ ’’~/:’ ~..::~,
B
thick (to stimulate the soft tissues of the anterior aspect of the abdomen), and radiographed (74 kvp, 300 r3a:~. for OT 1 sec). The tubes were replaced in ; rack and the htm was developed immediately. This procedure was repeated every 30 minutes until no tablets were visible. B: The experiment was carried out as before except that the tubes were agitated by had for I minute every !5 minutes to simulate to some extent the effect of gastric cm
motility. As shown iia Figure 2, tablets with the highelemental iron content (Numbers 2, 7 and 8) took longest to dissolve. est
Discussion
~~‘a~;.! ~. ~~£ti~t r°~ic~ic>~t’ra~>~~ ct#’tlt~
