Barium toxicity: Difference between revisions
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| Line 22: | Line 22: | ||
*Rapid onset | *Rapid onset | ||
*Within 1 hour of ingestion | *Within 1 hour of ingestion | ||
**Abdominal pain | **[[Abdominal pain]] | ||
**Nausea and vomiting | **[[Nausea and vomiting]] | ||
**Diarrhea | **[[Diarrhea]] | ||
*Hypokalemia | *[[Hypokalemia]] | ||
*Ventricular dysrhythmias | *[[Ventricular dysrhythmias]] | ||
*Hypotension | *[[Hypotension]] | ||
*Flaccid muscle weakness | *Flaccid muscle [[weakness]] | ||
*Respiratory failure | *[[Respiratory failure]] | ||
*Metabolic acidosis | *[[Metabolic acidosis]] | ||
*Lactic acidosis | *[[Lactic acidosis]] | ||
*Hypophosphatemia | *[[Hypophosphatemia]] | ||
*Rhabdomyolsis | *[[Rhabdomyolsis]] | ||
*Intravasation is rare but is most often seen with barium enemas causing bowel perforation | *Intravasation is rare but is most often seen with barium enemas causing bowel perforation | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 41: | Line 41: | ||
*BMP, including magnesium and phosphate | *BMP, including magnesium and phosphate | ||
*Serum barium >0.2mg/L is abnormal | *Serum barium >0.2mg/L is abnormal | ||
*EKG | *[[EKG]] | ||
*Cardiac monitor | *Cardiac monitor | ||
*CPK | *CPK | ||
| Line 49: | Line 49: | ||
==Management== | ==Management== | ||
*Decontamination | *Decontamination | ||
**Activated charcoal not recommended | **Activated charcoal ''not'' recommended | ||
**NG lavage | **NG lavage ''un''likely to benefit | ||
**Oral sodium sulfate or magnesium sulfate | **Oral sodium sulfate or [[magnesium sulfate]] | ||
***Prevents absorption by precipitating barium ions into insoluble barium 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 | ***Do not give these medications IV as they will cause precipitation in renal tubules | ||
***Magnesium sulfate | ***[[Magnesium sulfate]] | ||
****250mg/kg for children | ****250mg/kg for children | ||
****30g for adults | ****30g for adults | ||
*Supportive care | *Supportive care | ||
**Electrolyte repletion | **[[Electrolyte repletion]] | ||
**Ventilatory support as needed | **Ventilatory support as needed | ||
*Hemodialysis or CVVHDF | *[[Hemodialysis]] or CVVHDF | ||
**Both show increase elimination of barium | **Both show increase elimination of barium | ||
**CVVHDF showed to triple elimination with complete neurologic recovery in 24 hours in one case report <ref>Koch M, Appoloni O, Haufroid V, Vincent JL, Lheureux P. Acute barium intoxication and hemodiafiltration. J Toxicol Clin Toxicol. 2003;41:363-367.</ref> | **CVVHDF showed to triple elimination with complete neurologic recovery in 24 hours in one case report <ref>Koch M, Appoloni O, Haufroid V, Vincent JL, Lheureux P. Acute barium intoxication and hemodiafiltration. J Toxicol Clin Toxicol. 2003;41:363-367.</ref> | ||
Revision as of 14:24, 27 October 2020
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
- 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
- Aluminum toxicity
- Antimony toxicity
- Arsenic toxicity
- Barium toxicity
- Beryllium toxicity
- Bismuth toxicity
- Boron toxicity
- Cadmium toxicity
- Cesium toxicity
- Chromium toxicity
- Cobalt toxicity
- Copper toxicity
- Gold toxicity
- Iron toxicity
- Lead toxicity
- Lithium toxicity
- Manganese toxicity
- Mercury toxicity
- Nickel toxicity
- Phosphorus toxicity
- Platinum toxicity
- Selenium toxicity
- Silver toxicity
- Thallium toxicity
- Tin toxicity
- Vanadium toxicity
- Zinc 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
- ↑ 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