Ultrasonographic signs of acute appendicitis

Non-compressible tubular structure in the right lower quadrant

Wall thickness >2 mm
Overall diameter >6 mm
Free fluid in the right lower quadrant
Thickening of the mesentery
Localized tenderness with graded compression
Presence of a calcified appendicolith

Acute iron intoxication: Rapid overview

To obtain emergent consultation with a medical toxicologist, call the United States Poison Control Network at 1-80
(www.who.int/gho/phe/chemical_safety/poisons_centres/en/index.html).

History
What form of iron was ingested?
Ferrous gluconate (12 percent elemental iron)
Ferrous sulfate (20 percent elemental iron)
Ferrous fumarate (33 percent elemental iron)

How many mg/kg of elemental iron was ingested?

When did the ingestion occur?

Clinical features: Overlapping phases of clinical manifestations

Gastrointestinal phase: (30 minutes to 6 hours) Abdominal pain, vomiting, diarrhea, hematemesis, melena, le
Latent: (6 to 24 hours) Improvement in GI symptoms; may have poor perfusion, tachypnea, tachycardia

Shock and metabolic acidosis: (4 hours to 4 days) Hypovolemic, distributive, or cardiogenic shock with profoun
central nervous system dysfunction
Hepatotoxicity: (within 2 days) Coma, coagulopathy, jaundice. Severity is dose dependent.
Bowel obstruction: (2 to 4 weeks) Vomiting, dehydration, abdominal pain, usually gastric outlet obstruction

Diagnostic evaluation: For all patients with systemic symptoms, those who have ing

elemental iron ingested is unknown

Serum iron concentration: Measure serum iron concentration within 4 to 6 hours after ingestion (8 hours for e
Arterial or venous pH
Abdominal radiograph looking for radiopaque pills
Other initial labs: Electrolytes, BUN, creatinine, glucose, liver function tests, prothrombin,
partial thromboplastin time, CBC with differential, type and cross match

Management
Secure airway and breathing
Treat volume depletion aggressively with isotonic infusion

Whole bowel irrigation: For all patients with a significant number of pills in stomach and small intestine on rad
Deferoxamine: Continuous IV infusion (can cause hypotension). Begin at 15 mg/kg/hour.
May increase to 35/mg/kg/hour during first 24 hours for severe ingestions
. A toxicologist and/or regional poison control center should be consulted to determine the
optimum dose of deferoxamine and duration of therapy. Treat in the following circumstances:
Severe symptoms: Altered mental status, hemodynamic instability, persistent vomiting, diarrhea
Anion gap metabolic acidosis
Serum iron concentration >500 mcg/dL
Significant number of pills on x-ray