In general, syrup of ipecac is not used, because it may obscure the initial signs of clinical toxicity. Additionally, ipecac-induced vomiting is not thought to be more effective at gastric emptying than is iron-induced vomiting. Activated charcoal does not adsorb significantly to iron, and its use is not recommended in cases of isolated iron ingestion. Its use may also complicate endoscopy, should that be necessary. Cathartics should not be used. Orogastric lavage may not be effective if the ingested tablets are large or if several hours have elapsed since ingestion, but it may be used early after ingestion. Instillation of bicarbonate solution following gastric lavage has been advocated on the basis that free ferrous salt is converted into poorly absorbed ferrous carbonate. There are no data to support the efficacy of sodium bicarbonate or phosphosoda instillation during lavage to prevent iron absorption. Pills located on radiograph may indicate a potential for progressive toxicity and may guide decontamination.
Whole bowel irrigation with a polyethylene glycol solution has demonstrated efficacy in several pediatric patients with large iron ingestions. Administration of 250 to 500 mL/h in children and 2 L/h in adults via nasogastric tube may clear the GI tract of iron pills before absorption can occur. Endoscopy has been used to remove large iron loads but may not be practical where there are large numbers of pills requiring multiple endoscope insertions. Gastrotomy may also be an option where other measures are unsuccessful or impractical.11 Antiemetics such as metoclopramide or ondansetron can be used to treat nausea and vomiting.
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