Barium toxicity: Difference between revisions
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==Background== | ==Background== | ||
*Uses | |||
==Toxicokinetics== | **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== | ==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]] | |||
*[[Rhabdomyolysis]] | |||
*Intravasation is rare but is most often seen with barium enemas causing bowel perforation | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Heavy metals list}} | |||
==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 ''un''likely 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== | ||
*Consult Toxicology or | *Symptomatic admit to ICU | ||
*Asymptomatic after 6 hours of observation with a normal potassium can be discharged | |||
*Consult Toxicology or [[poison control]] | |||
==References== | ==References== | ||
<references/> | <references/> |
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
- Rhabdomyolysis
- 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