Difference between revisions of "Barium toxicity"

(Created page with "==Background== ==Toxicokinetics== ==Clinical Features== ==Differential Diagnosis== ===Heavy metal toxicity=== *Aluminum toxicity *Antimony toxicity *Arsenic t...")
 
Line 1: Line 1:
 
==Background==
 
==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==
 
==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==
 
==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==
 
==Differential Diagnosis==
 
===[[Heavy metal]] toxicity===
 
===[[Heavy metal]] toxicity===
Line 31: Line 60:
 
*[[Zinc toxicity]]
 
*[[Zinc toxicity]]
 
==Evaluation==
 
==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==
 
==Management==
 
*Decontamination
 
*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 <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>
 +
*Intravasation
 +
**Consider prophylactic antibiotics
 +
**IV extravasation outcomes improved with aspiration of barium sulfate
 
==Disposition==
 
==Disposition==
 +
*Symptomatic admit to ICU
 +
*Asymptomatic after 6 hours of observation with a normal potassium can be discharged
 
*Consult Toxicology or Poison Control Center
 
*Consult Toxicology or Poison Control Center
 
==References==
 
==References==

Revision as of 18:53, 9 August 2018

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 Center

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