Barium toxicity
Contents
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
- Aluminum toxicity
- Antimony toxicity
- Arsenic toxicity
- Barium toxicity
- Bismuth toxicity
- Cadmium 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
- 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