For Examiner Only
Case Pediatric Iron Toxicity
Author M. Cassara, DO and Z. Roit, MD
Reviewer Dougals Char, MD
Approved; Sept 18, 2005
ORAL CASE SUMMARY
CONTENT AREA
PEDIATRICS
SYNOPSIS OF CASE
This case involves a 2-year-old girl who presents with hypovolemic shock resulting from gastrointestinal
bleeding in the context of an accidental ingestion of iron tablets. The candidate needs to intubate the
patient, identify and treat hypovolemic shock (secondary to hemorrhage), elicit the history implying iron
toxicity (after providing initial stabilization measures), and initiate deferoxamine therapy.
SYNOPSIS OF HISTORY
The patient was found lethargic and minimally responsive in her parent’s bedroom. The babysitter states
that the baby is healthy, and was fine until she went to answer the telephone about 2 hours ago. The
babysitter returned after 30 minutes to find the child on the floor with an open bottle of brightly-colored
pills lying nearby. There were 2 pills left in the bottle but it originally held 30 tablets. The babysitter tried
to get help from the neighbor and attempted to call the child's mother. About 30 minutes later the child
complained of abdominal pain and vomited. She called 911. The babysitter states the mother has no
known medical problems but is four months pregnant. There are no other known medications in the
house.
SYNOPSIS OF PHYSICAL
Exam reveals pale, quiet, and minimally-responsive child. Dried blood and (old) vomit are visible in the
oropharynx and on the lips. Lips, conjunctivae, and skin are pale. Tachycardia is evident with
auscultation. The abdomen is without guarding or rigidity, but a weak cry can be elicited with palpation of
the epigastrium and left upper quadrant. Rectal exam is positive for gross blood. Extremities appear pale
and mottled and feel cool and dry. Capillary refill is delayed (5 seconds).
CRITICAL ACTIONS
1. Perform endotracheal intubation (PM)
2. Initiate appropriate resuscitation of hypovolemic shock with crystalloid and blood (PM)
3. Obtain blood glucose level (PS)
4. Recognize iron toxicity (DA)
5. Initiate appropriate decontamination/detoxification measures (must include deferoxamine
administration) (PM)
6.
7.
SCORING GUIDELINES
(Critical Action No.)
4. Score down if the candidate waits for serum iron levels to return before initiating deferoxamine therapy
5. Score down if the candidate attempts gastrointestinal decontamination without first securing the airway
5. Score down if the candidate elects to perform gastrointestinal decontamination with activated charcoal,
ipecac, or lavage.
FOR EXAMINER ONLY
For Examiner Only
Case Pediatric Iron Toxicity
PLAY OF CASE GUIDELINES
(Critical Action No.)
2. Resuscitation may be initiated by providing one or two 20 cc/kg crystalloid boluses intravenously prior
to initiating 10 cc/kg boluses of blood. Administration of crystalloid alone does not meet the critical action.
3. The empiric administration of dextrose using the appropriate concentration and dose in an attempt to
reverse this patient’s lethargy /mental status change will meet this critical action (4/5 exception)
5. If the candidate empirically initiates gastrointestinal decontamination in this patient without first
securing the airway, the patient will vomit blood and aspirate.
FOR EXAMINER ONLY
For Examiner Only
Case Pediatric Iron Toxicity
Critical Actions
1.
Perform endotracheal intubation (PM)
This critical action is met by the candidate endotracheally intubating the patient
Cueing Guideline: If candidate does not secure the airway, the patient will vomit blood and aspirate
during the primary survey
2. Initiate appropriate resuscitation of hypovolemic shock
with crystalloid and blood (PM)
This critical action is met by the candidate administering at least one 20 cc/kg bolus of crystalloid fluid
and at least one 10 cc/kg bolus of blood during this patient’s resuscitation
Cueing Guideline: If candidate does not administer blood, and continues to administer only crystalloid
fluids, the blood pressure will not improve
3.
Obtain blood glucose level (PS)
This critical action is met by the candidate obtaining a blood glucose level
Cueing Guideline:
4.
Recognize iron toxicity (DA)
This critical action is met by the candidate when he or she identifies iron toxicity as a cause of the
patient’s presentation, either, by recognizing the clinical toxidrome (gastrointestinal bleeding,
nausea, vomiting, hematemesis, hematochezia, and hypovolemic shock), by acquiring the
relevant history (pill fragments) from the babysitter, or by analyzing the results of laboratory test
ordered.
Cueing Guideline:
5. Initiate appropriate decontamination/detoxification
measures (must include deferoxamine administration) (PM)
This critical action is met by the candidate administering deferoxamine to the patient. The candidate may
consider other methods of decontaminating the patient (i.e. whole bowel irrigation), but these
other methods do not meet the critical action, and could complicate patient care and worsen the
patient’s outcome.
Cueing Guideline:
6.
This critical action is met by
Cueing Guideline:
For Examiner Only
Case Pediatric Iron Toxicity
History Data Panel
Age: 2
Sex: Female
Name: Sidney Smith
Method of Transportation: Ambulance
Person giving information: Babysitter
Presenting complaint: Found on the floor unconscious / minimally responsive by EMS
Onset and Description of Complaint: The babysitter states that the baby is healthy, and was fine at at
her normal baseline mental status and level of function. The babysitter then went to answer the
telephone about 2 hours ago. When she returned after 30 minutes, the babysitter found the child on the
floor with an open bottle of brightly-colored pills lying nearby. There were 2 pills left in the bottle but it
originally held 30 tablets. She tried to call the child's mother and went over to the neighbors to get help.
The child began to complian of abdominal pain about 30 minutes later and vomited once. The babysitter
got scared and called 911. The babysitter states the mother has no known medical problems but is four
months pregnant. There are no other known medications in the house.
Past Medical History
Allergies: none
Medical: none
Surgical: none
Last Meal: unknown
Habits
Smoking: n/a
Drugs: n/a
Alcohol: n/a
Family Medical History
Father: none
Mother: 4-months pregnant
Siblings: none
Social History
Married: n/a
Children: n/a
Employed: n/a
Education: n/a
PMD: Dr. Kidd
For Examiner Only
Case Pediatric Iron Toxicity
Physical Data Panel
General Appearance: minimally-responsive, pale, lethargic girl
Vital Signs:
BP
:
P
:
R
:
T
:
O2Sat
:
Glucose :
40 / palp
180 / minute
32 / minute
37.5 C (rectal)
97%
100 per EMS
Neurological: No focal or lateralizing signs, localizes painful stimuli
Mental Status: Lethargic, minimally-responsive
Head: Normal
Eyes: PERRL, but slightly sluggish; EOM normal
Ears: Normal
Mouth: Dried blood and vomit in oropharynx; gag reflex intact; slight drooling
Neck: Normal
Skin: Cool and dry; mottled and pale; capillary refill = 5 seconds
Chest: Tachypneic, but clear, breath sounds bilaterally (IF PATIENT HAS VOMITED WITH AN
UNPROTECTED AIRWAY, crackles are present on the right)
Heart: Tachycardic, without murmurs, rubs, or gallop
Abdomen: Soft, non-distended, mild tenderness elicited with palpation of the epigastrium and left upper
quadrant, no masses, no hepatosplenomegaly, no rigidity or guarding
Extremities: Pale palms and soles; capillary refill = 5 seconds
Rectal: Gross blood present (guaiac positive)
Pelvic: Normal
Back: No focal or lateralizing signs, localizes painful stimuli
Other exam findings: WEIGHT = 12 kilograms
For Examiner Only
Case Pediatric Iron Toxicity
Lab Data Panel
Stimulus #2 – CBC
WBC
Hgb
Hct
Platelets
Differential
Segs
Lymphs
Monos
Eos
15 /mm3
9 g/dL
21.3%
171/mm3
75%
20%
5%
1%
Stimulus #3 – Chemistry
Na+
140 mEq/L
K+
4.2 mEq/L
HCO3100 mEq/L
Cl11 mEq/L
Glucose
105 mg/dL
BUN
40 mg/dL
Creatinine
0.7 mg/dL
Stimulus #5 – Arterial blood gas
pH 7.27; pCO2 28 mm Hg; pO2 90 mm Hg; O2
Sat 96%
Stimulus #6 – Serum iron and TIBC levels
Iron level = 352 micrograms/dL; TIBC = 300
micrograms/dL
Stimulus #7 – ASA and APAP levels:
negative
Stimulus #8 –
Stimulus #9 –
Stimulus #10 –
Stimulus #11 –
VERBAL REPORTS
CXR = NORMAL
Stimulus #4 – Urinalysis
Color
Yellow
Sp Gravity
1.025
Glucose
Negative
Protein
Negative
Ketone
Positive
Leuk. Est.
Negative
Nitrite
Negative
WBC
0/HPF
RBC
0/HPF
AXR = RADIOPAQUE PILL FRAGMENTS
SEEN IN STOMACH AND IN SMALL
INTESTINE
HEAD CT = NORMAL
URINE TOXICOLOGY = UNAVAILABLE
For Examiner Only
Case Pediatric Iron Toxicity
Stimulus Inventory
Stimulus #1 – Emergency Admitting Form
Stimulus #2 – CBC
Stimulus #3 – Chemistry
Stimulus #4 – Urinalysis
Stimulus #5 –
Stimulus #6 –
Stimulus #7 –
Stimulus #8 –
Stimulus #9 –
Stimulus #10 –
Stimulus #11 –
FOR EXAMINER ONLY
Mock Oral Feedback Form – ABEM model
Case Pediatric Iron Toxicity Date:
Examiner:
Examinee:
Data acquisition
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Problem solving
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Patient management
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Resource utilization
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Health care provided
Worst
1
2
NOTES
3
4
5
6
7
8
Best
4
5
6
7
8
Best
Comprehension of path physiology
Worst
1
2
3
4
NOTES
5
6
7
8
Best
Clinical competence (overall)
Worst
1
2
3
NOTES
5
6
7
8
Best
Patient Interpersonal relations
Worst
1
2
3
NOTES
4
Critical Actions
Dangerous actions
1. Perform endotracheal intubation (PM)
 and omissions
2. Initiate appropriate resuscitation of hypovolemic shock
with crystalloid and blood (PM)
3. Obtain blood glucose level (PS)

4. Recognize iron toxicity (DA)

5. Initiate appropriate decontamination/detoxification
measures (must include deferoxamine administration)
(PM)
6.

7.

FOR EXAMINER ONLY


Mock Oral Feedback Form – Core Competencies
Case Pediatric Iron Toxicity Date:
Does not meet
expectations
Examiner:
Examinee:
Meets
Expectations
Exceeds
Expectations
1. Patient care
2. Medical
knowledge
3. Interpersonal
skills and
communication
4. Professionalism
5. Practice-based
learning and
improvement
6. Systems-based
practice
Critical Actions
Dangerous actions
1. Perform endotracheal intubation (PM)
 and omissions
2. Initiate appropriate resuscitation of hypovolemic shock
with crystalloid and blood (PM)
3. Obtain blood glucose level (PS)

4. Recognize iron toxicity (DA)

5. Initiate appropriate decontamination/detoxification
measures (must include deferoxamine administration)
(PM)
6.

7.

FOR EXAMINER ONLY


Stimulus #1 ABEM General Hospital
Emergency Admitting Form
Name
: Sidney Smith
Age
:2
Sex
: Female
Method of Transportation : Ambulance
Person giving information : Babysitter
Presenting complaint
: Found on the floor unconscious / minimally responsive
Background:
Found on the floor unconscious / minimally responsive
Vital Signs
BP:
40 / palp
P:
180 / minute
R:
32 / minute
T:
37.5 C (rectal)
Stimulus #2 – CBC
WBC
Hgb
Hct
Platelets
Differential
Segs
Lymphs
Monos
Eos
15 /mm3
9 g/dL
21.3%
171/mm3
75%
20%
5%
1%
Stimulus #3 – Chemistry
Na+
140 mEq/L
K+
4.2 mEq/L
HCO3100 mEq/L
Cl11 mEq/L
Glucose
100 mg/dL
BUN
40 mg/dL
Creatinine
0.7 mg/dL
Stimulus #4 – Urinalysis
Color
Yellow
Sp Gravity
1.025
Glucose
Negative
Protein
Negative
Ketone
Positive
Leuk. Est.
Negative
Nitrite
Negative
WBC
0/HPF
RBC
0/HPF