Case #3 Toxin and Discussion

QUESTIONS

I) What is the differential diagnosis of radiopaque toxins?

• C= Chlorohydrate, CCl4, Cocaine packets
• O= Opiate packets
• I= Iron and heavy metals (Lead, Arsenic, Mercury)
• N= Neuroleptic agent
• S= Sustained release, enteric coated preps

II) What drug levels should be ordered to help determine this child's toxin?

With the child demonstrating an anion gap metabolic acidosis with radiopaque pills on KUB, the differential is narrowed down to iron and possibly salicylates (enteric coated). Therefore, drug levels should be sent for ASA and iron.

III) What method of gastric decontamination is most appropriate for this patient?

A) Syrup of Ipecac- not indicated, child has already vomited several times

B) Activated charcoal- does not adsorb/bind iron well, still may administer if mixed drug ingestion suspected C) Gastric lavage- may be appropriate since actual time of ingestion is unknown, child symptomatic and iron may form concretion in stomach

D) Whole bowel irrigation- indicated with positive KUB;

considered safe in children

IV) What diagnostic/therapeutic test could be performed to assess the severity of this child's toxicity?

Deferoxamine challenge test can be performed IM or IV.

If the amount of free iron exceeds the body's total iron binding capacity, the urine will change to a "vin rose" color

Should be interpreted cautiously- not overly sensitive.

V) What are the indications and controversial endpoints for deferoxamine therapy?

• 24 hours after urine color returns to normal
• When iron level returns to normal (falsely lowered with deferoxamine therapy)
• Resolution of clinical symptoms and acidosis
• Reported cases of ARDS developing after prolonged chelation therapy with deferoxamine

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