Barium toxicity

Background
  • Uses
    • Pesticides
    • Depilatory
    • Radiographic contrast
  • Most toxicity is seen in pesticides, which contain barium carbonate
  • Barium sulfate is used in contrast
    • Insoluble
    • Rarely causes unintentional toxicity
    • When they occur typically seen with oral contrast and barium enemas

Toxicokinetics
  • Toxicity seen with as little as 200mg of barium salt
  • Lethal dose ranges from 1-30 g of barium salt
  • Absorption through the GI tract is 5-10%
  • Rapid rate of redistribution
  • Half life of 18-85 hours
  • Mostly eliminated via GI tract
    • 10-28% renal elimination
  • Barium induces hypokalemia by causing extracellular potassium to shift intracellularly

Clinical Features
  • Rapid onset
  • Within 1 hour of ingestion
    • Abdominal pain
    • Nausea and vomiting
    • Diarrhea
  • Hypokalemia
  • Ventricular dysrhythmias
  • Hypotension
  • Flaccid muscle weakness
  • Respiratory failure
  • Metabolic acidosis
  • Lactic acidosis
  • Hypophosphatemia
  • Rhabdomyolsis
  • Intravasation is rare but is most often seen with barium enemas causing bowel perforation

Differential Diagnosis

Heavy metal toxicity

Evaluation
  • BMP, including magnesium and phosphate
  • Serum barium >0.2mg/L is abnormal
  • EKG
  • Cardiac monitor
  • CPK
  • pH
  • Lactate
  • Consider radiographs, such as CT chest and abdomen to identify location of barium contrast in event of Intravasation

Management
  • Decontamination
    • Activated charcoal not recommended
    • NG lavage unlikely to benefit
    • Oral sodium sulfate or magnesium sulfate
      • Prevents absorption by precipitating barium ions into insoluble barium sulfate
      • Do not give these medications IV as they will cause precipitation in renal tubules
      • Magnesium sulfate
        • 250mg/kg for children
        • 30g for adults
  • Supportive care
    • Electrolyte repletion
    • Ventilatory support as needed
  • Hemodialysis or CVVHDF
    • Both show increase elimination of barium
    • CVVHDF showed to triple elimination with complete neurologic recovery in 24 hours in one case report [1]
  • Intravasation
    • Consider prophylactic antibiotics
    • IV extravasation outcomes improved with aspiration of barium sulfate

Disposition
  • Symptomatic admit to ICU
  • Asymptomatic after 6 hours of observation with a normal potassium can be discharged
  • Consult Toxicology or poison control

References
  1. Koch M, Appoloni O, Haufroid V, Vincent JL, Lheureux P. Acute barium intoxication and hemodiafiltration. J Toxicol Clin Toxicol. 2003;41:363-367.

Dawson, A. Barium. In: Goldfrank's Toxicologic Emergencies. 9th Ed. New York: McGraw-Hill; 2011: 1434-1436

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