# Episode 229: Iron Poisoning

An episode of [Core EM - Emergency Medicine Podcast](https://invisiblenetwork.ai/podcast/1005774516), 26 Oct 2026, 12 min.

Audio: https://media.blubrry.com/coreem/content.blubrry.com/coreem/Iron_Poisoning.mp3

Iron overdose in the ED: five stages, elemental iron math, decontamination, and deferoxamine. Hosts: Brian Chastain, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Iron_Poisoning.mp3 Download Leave a Comment Tags: Toxicology Podcast Video Show Notes Core EM Modular CME Course Maximize your commute with the new Core EM Modular CME Course, featuring the most essential content distilled from our top-rated podcast episodes. This course offers 12 audio-based modules packed with pearls! Information and link below. Course Highlights: • Credit: 12.5 AMA PRA Category 1 Credits™ • Curriculum: Comprehensive coverage of Core Emergency Medicine, with 12 modules spanning from Critical Care to Pediatrics. • Cost: • Free for NYU Learners • $250 for Non-NYU Learners Click Here to Register and Begin Module 1 Iron Poisoning Stages at a Glance Stage Timing What’s happening 1 · GI 30 min–6 h Direct corrosive GI injury; abd pain, vomiting 2 · Latent 6–24 h GI sx improve; iron redistributing into tissues 3 · Shock / acidosis 6–72 h Profound metabolic acidosis → shock, MSOF 4 · Hepatotoxicity 12–96 h Hepatotoxicity → fulminant liver failure 5 · GI scarring 2–8 wks Gastric outlet obstruction, GI tract scarring The Case • 31M w/ hx depression, anxiety; found minimally responsive at home by family • EMS: HR 67, SpO2 96% on 2 L NC, BP 46/21; withdraws to pain, not opening eyes → 2 L IVF + push-dose epi en route • ED: BP ↑ to 90/61, other VS unchanged; dried vomit on lips/shirt; breathing comfortably, protecting airway • POC VBG: pH 7.24, pCO2 33, pO2 25, HCO3 14, lactate 2.5 • ECG: NSR, otherwise unremarkable → get an ECG in any possible toxic ingestion • Additional 30 mL/kg bolus + norepi gtt • Family arrives → bottle of iron pills under the pt’s bed Pathophysiology • Free iron = multisystem oxidative injury • Primary mechanism: free radical generation + lipid peroxidation → damages cellular and mitochondrial membranes throughout the body • Profound metabolic acidosis via 2 routes: uncoupled oxidative phosphorylation → anaerobic metabolism → lactate; Fe³⁺ reacts w/ water → releases 3 H⁺ → excess acid • Direct mucosal necrosis in the gut (corrosive injury) • Negative inotrope on the myocardium → hypotension, cardiogenic shock in large ingestions Clinical Stages • Classic progression after large ingestions; stages overlap and pts can present anywhere along the timeline • Stage 1, GI (30 min–6 h): direct GI tract injury; abd pain, vomiting. Persistent vomiting = very sensitive indicator of a serious ingestion • Stage 2, latent (6–24 h): GI sx improve, but iron is redistributing into the tissues → ongoing damage • The latent-phase trap: pts look like they’re turning the corner right before they crump. Contrast: pts never symptomatic >6 h after ingestion are unlikely to develop toxicity (AAPCC 2005); GI sx that improve ≠ never symptomatic • Stage 3, shock (6–72 h): tissue iron → profound acidosis → shock, MSOF • Stage 4, hepatotoxicity (12–96 h): hepatotoxicity → fulminant liver failure • Stage 5, GI scarring (2–8 wks): gastric outlet obstruction, GI tract scarring from the initial corrosive injury Diagnosis / Workup Imaging • Emergent plain-film abd XR in any suspected iron ingestion → intact adult iron tabs are radiopaque • Confirms pills still in the stomach/GI tract → helps decide on WBI • Negative XR ≠ no ingestion: chewables, liquid formulations and already-dissolved tabs often don’t show up Serum Iron • Draw 4–6 h post-ingestion for regular formulations, ~8 h for extended release • Often hard to interpret → time of ingestion and formulation frequently unknown • >500 mcg/dL → serious systemic toxicity • >1,000 mcg/dL → very significant mortality Elemental Iron Math • Toxicity tracks the elemental iron dose, not the mass of the pill Salt Elemental Fe Per 325 mg tab Ferrous sulfate ~20% ~65 mg Ferrous fumarate ~33% 106 mg Ferrous gluconate ~12% ~36–38 mg • <20 mg/kg elemental Fe → usually…

## Chapters

- 0:00 Intro
- 0:30 The Case
- 1:59 Pathophysiology
- 3:08 The Five Clinical Stages
- 4:45 Workup: X-ray, Iron Levels & Elemental Iron
- 6:38 Decontamination: WBI, Not Charcoal
- 8:32 Deferoxamine
- 10:25 Four Take-Home Points
- 11:36 Wrap-up

## Transcript

[0:00] Brian Gilberti: Welcome back to Core EM.
[0:01] I'm Brian Gilberti, and today we're breaking down a classic tox ingestion
[0:04] that can rapidly spiral into multi-organ failure.
[0:07] Joining me to do this is Dr. Brian Chastain,
[0:10] one of our phenomenal senior residents and, most importantly, a fellow Brian.
[0:14] Brian Chastain: Thanks, Brian. It's a pleasure to be here,
[0:15] especially in the presence of another Brian.
[0:17] Brian Gilberti: Feeling is definitely mutual, Brian.
[0:19] And believe it or not, this is actually a podcast milestone today:
[0:23] our very first Brian-to-Brian episode. And I'm glad we finally made it to this point
[0:27] and made it happen. But let's jump straight into the medicine.
[0:30] Walk us through how a patient like this actually presents to the resuscitation bay,
[0:35] and set the scene by giving us a case.
[0:38] Brian Chastain: Yeah, so I'll give you a little background to start the case.
[0:40] We have a 31-year-old male with a history of depression and anxiety who was found
[0:44] kind of minimally responsive at home by family members.
[0:47] They called EMS, and when the EMS team arrived,
[0:49] they reported that the patient had a heart rate of 67,
[0:52] was satting at 96% on 2 liters nasal cannula, and had a pretty low blood pressure,
[0:57] down to 46 over 21. The patient was withdrawing to pain but wasn't really opening
[1:01] his eyes, so they gave him 2 liters of IV fluid and a push dose of epi on the way
[1:06] to the emergency department. When he arrived,
[1:08] his blood pressure had improved a little bit,
[1:10] but his other vital signs were pretty unchanged.
[1:12] The blood pressure was now 90 over 61.
[1:14] He was noted to have some dried vomit on his lips and on his shirt,
[1:17] but was otherwise breathing comfortably and protecting his airway.
[1:20] A point-of-care VBG was obtained, and it showed a pH of 7.24, a pCO2 of 33,
[1:27] a pO2 of 25 and a bicarb of 14, also with a lactate of 2.5.
[1:32] Again, the patient was withdrawing all four extremities to painful stimuli
[1:36] but wasn't really opening his eyes.
[1:38] In any case where there might be a toxic ingestion,
[1:40] we always want to get an EKG as well.
[1:42] And this patient's EKG thankfully showed normal sinus rhythm and was otherwise
[1:45] unremarkable. He got an additional 30 cc per kg fluid bolus and was started
[1:50] on a norepi drip to maintain his blood pressure.
[1:52] Eventually, a family member was able to arrive and told us that they found a bottle
[1:56] of iron pills underneath the patient's bed.
[1:59] Brian Gilberti: And just like that, the biggest piece of the puzzle drops
[2:01] into place. Now that we know what we're dealing with,
[2:03] let's lay down the groundwork and talk pathophys.
[2:06] At the cellular level, a massive iron overdose is basically like throwing
[2:10] a multisystem oxidative hand grenade into the body, right?
[2:14] So walk us through why iron is so devastating once it gets past the gut.
[2:18] Brian Chastain: Yeah, I can't think of a better way to describe the toxic effects
[2:21] here. Firstly, the primary mechanism is the generation of free radicals and lipid
[2:25] peroxidation, which damages both cellular and mitochondrial membranes throughout
[2:30] different parts of the body.
[2:31] As well, iron produces a profound metabolic acidosis through two major routes.
[2:36] Firstly, it uncouples oxidative phosphorylation,
[2:39] leading to anaerobic metabolism and lactate formation.
[2:42] This mitochondrial dysfunction can be very disruptive.
[2:45] As well, when the iron 3+ form reacts with water, it releases three protons,
[2:50] which further leads to excess acid production within the body.
[2:54] Outside of these acid-producing effects,
[2:56] iron additionally causes direct mucosal necrosis in the gut and acts as a negative
[3:01] inotrope on the myocardium.
[3:03] This together can lead to hypotension and cardiogenic shock in patients with large
[3:07] ingestions.
[3:08] Brian Gilberti: So you have direct corrosive injury in the gut,
[3:11] followed by systemic cellular destruction and shock.
[3:14] How does all that translate clinically at the bedside, Brian?
[3:17] Iron poisoning is classically divided into five distinct clinical stages.
[3:20] So walk us through that timeline.
[3:22] Brian Chastain: Yeah, so like many toxic substances,
[3:24] iron has a classic progression that we often see in patients who've taken large
[3:28] doses. The first part of this is the GI phase.
[3:33] This phase acts primarily through direct injury to the GI tract and occurs pretty
[3:37] rapidly over the first 30 minutes to six hours.
[3:40] Patients often have substantial abdominal pain, vomiting,
[3:44] and this persistent vomiting is actually a very sensitive indicator for a serious
[3:48] iron ingestion. Next, we have the latent stage,
[3:51] which occurs over the next six to 24 hours.
[3:54] Patients often have improvement in these GI symptoms,
[3:57] but actually the iron is just being redistributed into the tissues,
[4:00] where it's able to cause further damage.
[4:02] Along these lines, by stage three, we get the shock phase.
[4:05] Anywhere between six hours and 72 hours,
[4:08] this redistribution of the iron into the tissues results in the profound acidosis
[4:13] that we discussed earlier, leading to shock and multisystem organ failure.
[4:17] As part of that multisystem organ failure, we get to phase four,
[4:20] which is the hepatotoxicity phase.
[4:22] Over the 12- to 96-hour period,
[4:26] patients often develop hepatotoxicity and fulminant liver failure.
[4:30] Finally, after all of these other phases have run their course,
[4:33] two to eight weeks after a toxic ingestion,
[4:36] patients can also develop gastric outlet obstruction and get substantial GI tract
[4:40] scarring just from that direct initial tissue damage of the iron sitting in the gut.
[4:45] Brian Gilberti: All right, and a lot to consider here.
[4:46] That second latent phase is such a dangerous clinical trap.
[4:49] They look like they're turning the corner right before they crump.
[4:52] And since patients can roll into the ED at any point along that timeline,
[4:56] the presentation is super variable for us.
[4:58] With that in mind, how do you approach this workup?
[5:00] What are the key diagnostics and numbers we need to be chasing?
[5:04] Brian Chastain: Yeah, I think firstly, with any suspected iron ingestion,
[5:07] we want to get an emergent plain film abdominal radiograph.
[5:10] This helps us look for the iron pills that could still be in the stomach,
[5:13] as they are radiopaque, and they might be able to be seen on said X-ray.
[5:18] Outside of that, we want to get serum iron levels as well.
[5:21] These should be drawn ideally four to six hours post-ingestion for a regular
[5:25] formulation of iron, or around eight hours for an extended release.
[5:29] This can often be a little bit difficult to interpret because we often don't know
[5:33] when the iron was ingested or what type of iron was ingested as well.
[5:36] So that does complicate the picture when we're looking at iron levels.
[5:39] However, a serum iron level greater than 500 micrograms per deciliter indicates
[5:44] serious systemic toxicity, while an iron level greater than 1,000 micrograms
[5:48] per deciliter is associated with very significant mortality in patients.
[5:52] In iron toxicity, we don't necessarily worry about the mass of the pill itself.
[5:56] We actually worry about the elemental iron dose.
[5:59] And there are many different forms of iron pills that all differ in their elemental
[6:03] iron content. So common forms are things like ferrous sulfate,
[6:07] which contains roughly 65 milligrams of elemental iron per 325 mg pill,
[6:12] while other forms, like ferrous fumarate, contain 106 mg of elemental iron per 325
[6:18] mg pill. So using the elemental iron content of the pill,
[6:22] you can determine if you anticipate a toxic dose based off the amount that was taken
[6:26] by the patient. A dose less than 20 mg per kg of elemental iron is usually
[6:30] asymptomatic, while doses greater than 60 mg per kg is kind of the threshold
[6:35] for serious toxicity and possible death in patients.
[6:38] Brian Gilberti: Excellent, Brian. And I'm glad you brought up that point,
[6:40] because this distinction between tablet weight and actual elemental iron is critical
[6:44] when we're doing the math at the bedside.
[6:46] Now, let's say we've confirmed a massive, potentially lethal ingestion.
[6:50] What are the immediate priorities in the ED to get that iron out?
[6:53] And just as importantly, what classic tox pitfall should we be avoiding here?
[6:58] Brian Chastain: Yeah, I think one of the first steps in any toxicologic ingestion
[7:02] is decontamination. There's many ways to do this.
[7:05] One of the more common ones is activated charcoal.
[7:07] But unfortunately, because iron is a metal, it does not bind to activated charcoal.
[7:11] So there's no utility in giving activated charcoal,
[7:14] and you can actually harm the patient if you give it to them,
[7:16] as they could be at a higher risk for aspiration or other complications.
[7:20] The main decontamination strategy we use is actually whole bowel irrigation.
[7:24] This is especially helpful if we're seeing iron pills on the X-ray,
[7:28] as we can flush those iron pills out,
[7:30] hopefully before they're absorbed and cause further damage to the GI tract
[7:33] and that systemic absorption.
[7:35] Normally we use PEG-ELS, or polyethylene glycol electrolyte solution,
[7:40] and we give this at a pretty high rate.
[7:42] We usually do 1.5 to 2 liters per hour until the fluid coming out of the rectum
[7:47] is actually clear. This is a lot for patients to take in,
[7:51] so we often put it in an NG tube just to facilitate this large volume going through
[7:55] the GI tract. Generally, gastric lavage isn't used often unless there's still
[8:00] a large amount of iron pills still noted in the stomach,
[8:04] as there's risks of aspiration, and you can always injure the GI tract directly when
[8:08] you're doing things like gastric lavage,
[8:11] especially because it's not something we're overly familiar with doing anymore
[8:14] in the ED, which just puts it at a high risk for more complications.
[8:17] Brian Gilberti: Perfect, Brian, some great practical stuff you're bringing up here.
[8:19] So, just to recap: skip the charcoal, hold off on routine lavage,
[8:23] and reach for whole bowel irrigation if you see pills on KUB.
[8:27] And of course, get your tox colleagues involved and your local poison control center
[8:30] on the line early in these cases.
[8:32] Now, once that iron is already absorbed into the bloodstream,
[8:35] we're gonna have to chelate it, right?
[8:37] So tell us about our antidote here: deferoxamine.
[8:40] Brian Chastain: Yeah, this is actually a pretty cool medication.
[8:42] And it's nice to have an antidote, because not all of our tox ingestions do.
[8:46] Deferoxamine is actually isolated from bacteria,
[8:50] and it is able to bind the elemental iron in the blood and allow it to be excreted
[8:54] renally in the urine. When to give deferoxamine,
[8:57] we usually have a few different indications: one being shock, altered mental status,
[9:01] persistent GI symptoms, so that persistent vomiting we talked about earlier,
[9:05] serum iron levels that are greater than 500 micrograms per deciliter,
[9:09] or a greater than 60 milligram per kilogram elemental iron ingestion based off
[9:13] of the type of iron that the patient took.
[9:16] With this medication, we start at 5 milligrams per kilogram per hour,
[9:20] and we titrate up to roughly 15 milligrams per kilogram per hour.
[9:24] Some protocols allow for going higher than this,
[9:26] up to rates like 30 milligrams per kilogram per hour in the first 24 hours.
[9:31] However, you do have to watch for hypotension,
[9:33] as these medications can worsen the hypotension that's already existing in patients
[9:37] who often have large iron intoxications.
[9:40] What we look for is actually a color change in the urine.
[9:43] We're looking for a red-orange color change that is showing the deferoxamine binding
[9:49] and excreting the elemental iron within the urine.
[9:52] This can be a helpful indicator, but it's actually not quantitative,
[9:56] and it shouldn't be used to really guide the duration of therapy.
[9:59] Sometimes the iron comes out and you can see it well in the urine,
[10:03] other times you cannot, but regardless,
[10:05] we still want to continue giving the deferoxamine even if the urine has cleared
[10:09] color. Finally, we usually stop the deferoxamine when the patient is clinically well
[10:13] and their anion gap acidosis has resolved.
[10:17] Brian Gilberti: So like you said, don't get fooled by the urine color alone.
[10:19] Treat the patient's clinical status and wait until they've closed that anion gap.
[10:23] It doesn't get much more classic tox than that right there.
[10:25] Now, we covered a ton of high-yield ground today.
[10:28] Before we wrap it up, distill this all down for us and leave our listeners with four
[10:32] key take-home points.
[10:33] Brian Chastain: Yeah, I think the first take-home point is treating the patient
[10:36] and not the number. If the patient's in shock, has a profound metabolic acidosis,
[10:40] there's very little harm, other than this hypotension that we talked about,
[10:43] to starting deferoxamine, even if the serum iron level hasn't peaked or is lower
[10:48] than expected. Secondly, we always want to calculate the amount of elemental
[10:51] iron if we have any idea of what type of pills the patient has ingested.
[10:56] All of the different forms have different concentrations of elemental iron,
[10:59] and so this can help us to identify whether we anticipate this dose being toxic
[11:04] or not. Thirdly, we always want to get an X-ray in patients who may have ingested
[11:09] iron, as this plain film can confirm the presence of iron tablets and also help us
[11:14] decide whether we need to have the patient undergo whole bowel irrigation.
[11:17] Finally, we want to beware of the iron toxicity's latent phase.
[11:23] When the patient has improvement in GI symptoms,
[11:25] this doesn't always mean that the toxic effects have run their course,
[11:28] as this is often the phase where the iron is being absorbed,
[11:30] and it precedes the profound cardiovascular collapse and shock that can occur once
[11:35] it's gotten into the tissues.
[11:36] Brian Gilberti: Excellent. That's a wrap for this episode.
[11:38] And our listeners know that normally we close out with some Radiohead,
[11:41] but for this episode, since we're talking about metal,
[11:44] we're going to have to close out with some heavy metal.
[11:45] So, Brian, thanks for being in the studio with us.
[11:47] Brian Chastain: Yeah, thank you so much for having me.
[11:49] I hope we can have many more Brian-to-Brian chats in the future.
[11:51] Brian Gilberti: Absolutely.
[11:52] \[Outro music\]

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