Iron ingestion

An evidence-based consensus guideline for out-of-hospital management

Anthony S. Manoguerra, Andrew R. Erdman, Lisa L. Booze, Gwenn Christianson, Paul M. Wax, Elizabeth J. Scharman, Alan D. Woolf, Peter Chyka, Daniel C. Keyes, Kent R. Olson, E. Martin Caravati, William G. Troutman

Research output: Contribution to journalReview article

46 Citations (Scopus)

Abstract

From 1983 to 1991, iron caused over 30% of the deaths from accidental ingestion of drug products by children. An evidence-based expert consensus process was used to create this guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the primary author. The entire panel discussed and refined the guideline before its distribution to secondary reviewers for comment. The panel then made changes in response to comments received. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial management of patients with suspected ingestions of iron by 1) describing the manner in which an ingestion of iron might be managed, 2) identifying the key decision elements in managing cases of iron ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of iron alone and is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. The panel's recommendations follow; the grade of recommendation is in parentheses. 1) Patients with stated or suspected self-harm or who are victims of malicious administration of an iron product should be referred to an acute care medical facility immediately. This activity should be guided by local poison center procedures. In general, this should occur regardless of the amount ingested (Grade D). 2) Pediatric or adult patients with a known ingestion of 40 mg/kg or greater of elemental iron in the form of adult ferrous salt formulations or who have severe or persistent symptoms related to iron ingestion should be referred to a healthcare facility for medical evaluation. Patients who have ingested less than 40 mg/kg of elemental iron and who are having mild symptoms can be observed at home. Mild symptoms such as vomiting and diarrhea occur frequently. These mild symptoms should not necessarily prompt referral to a healthcare facility. Patients with more serious symptoms, such as persistent vomiting and diarrhea, alterations in level of consciousness, hematemesis, and bloody diarrhea require referral. The same dose threshold should be used for pregnant women, however, when calculating the mg/kg dose ingested, the pre-pregnancy weight of the woman should be used (Grade C). 3) Patients with ingestions of children's chewable vitamins plus iron should be observed at home with appropriate follow-up. The presence of diarrhea should not be the sole indicator for referral as these products are often sweetened with sorbitol. Children may need referral for the management of dehydration if vomiting or diarrhea is severe or prolonged (Grade C). 4) Patients with unintentional ingestions of carbonyl iron or polysaccharide-iron complex formulations should be observed at home with appropriate follow-up (Grade C). 5) Ipecac syrup, activated charcoal, cathartics, or oral complexing agents, such as bicarbonate or phosphate solutions, should not be used in the out-of-hospital management of iron ingestions (Grade C). 6) Asymptomatic patients are unlikely to develop symptoms if the interval between ingestion and the call to the poison center is greater than 6 hours. These patients should not need referral or prolonged observation. Depending on the specific circumstances, follow-up calls might be indicated (Grade C).

Original languageEnglish (US)
Pages (from-to)553-570
Number of pages18
JournalClinical Toxicology
Volume43
Issue number6
DOIs
StatePublished - Oct 21 2005

Fingerprint

Iron
Eating
Guidelines
Diarrhea
Referral and Consultation
Poisons
Vomiting
Ipecac
Cathartics
Delivery of Health Care
Hematemesis
Pediatrics
Sorbitol
Triage
Charcoal
Bicarbonates
Consciousness
Dehydration
Health care
Vitamins

All Science Journal Classification (ASJC) codes

  • Toxicology
  • Health, Toxicology and Mutagenesis

Cite this

Manoguerra, A. S., Erdman, A. R., Booze, L. L., Christianson, G., Wax, P. M., Scharman, E. J., ... Troutman, W. G. (2005). Iron ingestion: An evidence-based consensus guideline for out-of-hospital management. Clinical Toxicology, 43(6), 553-570. https://doi.org/10.1081/CLT-200068842

Iron ingestion : An evidence-based consensus guideline for out-of-hospital management. / Manoguerra, Anthony S.; Erdman, Andrew R.; Booze, Lisa L.; Christianson, Gwenn; Wax, Paul M.; Scharman, Elizabeth J.; Woolf, Alan D.; Chyka, Peter; Keyes, Daniel C.; Olson, Kent R.; Caravati, E. Martin; Troutman, William G.

In: Clinical Toxicology, Vol. 43, No. 6, 21.10.2005, p. 553-570.

Research output: Contribution to journalReview article

Manoguerra, AS, Erdman, AR, Booze, LL, Christianson, G, Wax, PM, Scharman, EJ, Woolf, AD, Chyka, P, Keyes, DC, Olson, KR, Caravati, EM & Troutman, WG 2005, 'Iron ingestion: An evidence-based consensus guideline for out-of-hospital management', Clinical Toxicology, vol. 43, no. 6, pp. 553-570. https://doi.org/10.1081/CLT-200068842
Manoguerra AS, Erdman AR, Booze LL, Christianson G, Wax PM, Scharman EJ et al. Iron ingestion: An evidence-based consensus guideline for out-of-hospital management. Clinical Toxicology. 2005 Oct 21;43(6):553-570. https://doi.org/10.1081/CLT-200068842
Manoguerra, Anthony S. ; Erdman, Andrew R. ; Booze, Lisa L. ; Christianson, Gwenn ; Wax, Paul M. ; Scharman, Elizabeth J. ; Woolf, Alan D. ; Chyka, Peter ; Keyes, Daniel C. ; Olson, Kent R. ; Caravati, E. Martin ; Troutman, William G. / Iron ingestion : An evidence-based consensus guideline for out-of-hospital management. In: Clinical Toxicology. 2005 ; Vol. 43, No. 6. pp. 553-570.
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abstract = "From 1983 to 1991, iron caused over 30{\%} of the deaths from accidental ingestion of drug products by children. An evidence-based expert consensus process was used to create this guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the primary author. The entire panel discussed and refined the guideline before its distribution to secondary reviewers for comment. The panel then made changes in response to comments received. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial management of patients with suspected ingestions of iron by 1) describing the manner in which an ingestion of iron might be managed, 2) identifying the key decision elements in managing cases of iron ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of iron alone and is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. The panel's recommendations follow; the grade of recommendation is in parentheses. 1) Patients with stated or suspected self-harm or who are victims of malicious administration of an iron product should be referred to an acute care medical facility immediately. This activity should be guided by local poison center procedures. In general, this should occur regardless of the amount ingested (Grade D). 2) Pediatric or adult patients with a known ingestion of 40 mg/kg or greater of elemental iron in the form of adult ferrous salt formulations or who have severe or persistent symptoms related to iron ingestion should be referred to a healthcare facility for medical evaluation. Patients who have ingested less than 40 mg/kg of elemental iron and who are having mild symptoms can be observed at home. Mild symptoms such as vomiting and diarrhea occur frequently. These mild symptoms should not necessarily prompt referral to a healthcare facility. Patients with more serious symptoms, such as persistent vomiting and diarrhea, alterations in level of consciousness, hematemesis, and bloody diarrhea require referral. The same dose threshold should be used for pregnant women, however, when calculating the mg/kg dose ingested, the pre-pregnancy weight of the woman should be used (Grade C). 3) Patients with ingestions of children's chewable vitamins plus iron should be observed at home with appropriate follow-up. The presence of diarrhea should not be the sole indicator for referral as these products are often sweetened with sorbitol. Children may need referral for the management of dehydration if vomiting or diarrhea is severe or prolonged (Grade C). 4) Patients with unintentional ingestions of carbonyl iron or polysaccharide-iron complex formulations should be observed at home with appropriate follow-up (Grade C). 5) Ipecac syrup, activated charcoal, cathartics, or oral complexing agents, such as bicarbonate or phosphate solutions, should not be used in the out-of-hospital management of iron ingestions (Grade C). 6) Asymptomatic patients are unlikely to develop symptoms if the interval between ingestion and the call to the poison center is greater than 6 hours. These patients should not need referral or prolonged observation. Depending on the specific circumstances, follow-up calls might be indicated (Grade C).",
author = "Manoguerra, {Anthony S.} and Erdman, {Andrew R.} and Booze, {Lisa L.} and Gwenn Christianson and Wax, {Paul M.} and Scharman, {Elizabeth J.} and Woolf, {Alan D.} and Peter Chyka and Keyes, {Daniel C.} and Olson, {Kent R.} and Caravati, {E. Martin} and Troutman, {William G.}",
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AU - Manoguerra, Anthony S.

AU - Erdman, Andrew R.

AU - Booze, Lisa L.

AU - Christianson, Gwenn

AU - Wax, Paul M.

AU - Scharman, Elizabeth J.

AU - Woolf, Alan D.

AU - Chyka, Peter

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N2 - From 1983 to 1991, iron caused over 30% of the deaths from accidental ingestion of drug products by children. An evidence-based expert consensus process was used to create this guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the primary author. The entire panel discussed and refined the guideline before its distribution to secondary reviewers for comment. The panel then made changes in response to comments received. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial management of patients with suspected ingestions of iron by 1) describing the manner in which an ingestion of iron might be managed, 2) identifying the key decision elements in managing cases of iron ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of iron alone and is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. The panel's recommendations follow; the grade of recommendation is in parentheses. 1) Patients with stated or suspected self-harm or who are victims of malicious administration of an iron product should be referred to an acute care medical facility immediately. This activity should be guided by local poison center procedures. In general, this should occur regardless of the amount ingested (Grade D). 2) Pediatric or adult patients with a known ingestion of 40 mg/kg or greater of elemental iron in the form of adult ferrous salt formulations or who have severe or persistent symptoms related to iron ingestion should be referred to a healthcare facility for medical evaluation. Patients who have ingested less than 40 mg/kg of elemental iron and who are having mild symptoms can be observed at home. Mild symptoms such as vomiting and diarrhea occur frequently. These mild symptoms should not necessarily prompt referral to a healthcare facility. Patients with more serious symptoms, such as persistent vomiting and diarrhea, alterations in level of consciousness, hematemesis, and bloody diarrhea require referral. The same dose threshold should be used for pregnant women, however, when calculating the mg/kg dose ingested, the pre-pregnancy weight of the woman should be used (Grade C). 3) Patients with ingestions of children's chewable vitamins plus iron should be observed at home with appropriate follow-up. The presence of diarrhea should not be the sole indicator for referral as these products are often sweetened with sorbitol. Children may need referral for the management of dehydration if vomiting or diarrhea is severe or prolonged (Grade C). 4) Patients with unintentional ingestions of carbonyl iron or polysaccharide-iron complex formulations should be observed at home with appropriate follow-up (Grade C). 5) Ipecac syrup, activated charcoal, cathartics, or oral complexing agents, such as bicarbonate or phosphate solutions, should not be used in the out-of-hospital management of iron ingestions (Grade C). 6) Asymptomatic patients are unlikely to develop symptoms if the interval between ingestion and the call to the poison center is greater than 6 hours. These patients should not need referral or prolonged observation. Depending on the specific circumstances, follow-up calls might be indicated (Grade C).

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