A 9-year-old male is brought to the emergency room after intentionally ingesting half a bottle of iron tablets (coated with plum-flavored sugar) 6 hours ago; he now complains of abdominal pain and diarrhea.

He has been feeling weak and lightheaded, with palpitations and a metallic taste in his mouth. He had two episodes of bluish-green vomit followed by a large hematemesis.

VS: marked tachycardia (HR 120); hypotension (BP 90/50); no fever. PE: pulse weak; patient is pale and dehydrated with cold and clammy skin; lungs clear; abdomen tender to deep palpation, predominandy in epigastrium, with no peritoneal signs; neurologic exam normal; rectal exam discloses black, tarry stool.

Markedly elevated serum iron levels (> 500 mg/dL). UA: rose-wine-colored urine. ABGs: metabolic acidosis. BUN and creatinine elevated.

XR, abdomen: multiple radiopaque iron tablets in GI tract from stomach to jejunum. Endoscopy: diffuse hemorrhagic gastritis with extensive necrosis and sloughing of mucosa.

Gastric lavage with bicarbonate solution (to form ferrous carbonate, which is not absorbed well) or induction of vomiting. Treat acidosis; treat shock with IV fluids and chelation therapy with deferoxamine

Mortality due to acute iron overdose may reach 25% or more, mainly in children. There may be marked dehydration and shock.

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