Difference between revisions of "Barium toxicity"

(Text replacement - "Poison Control Center" to "poison control")
(Tag: mobile edit)
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*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==
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*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
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==Management==
 
==Management==
 
*Decontamination
 
*Decontamination
**Activated charcoal not recommended
+
**Activated charcoal ''not'' recommended
**NG lavage unlikely to benefit
+
**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

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
  • 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