Barium carbonate intoxication

Clinical features and management strategies of acute soluble barium poisoning: a review of case reports

Soluble barium salts including barium carbonate, nitrate, acetate, and chloride are commonly used in the manufacture of ceramics, insecticides, and rodenticides. Soluble barium salts are highly toxic to humans if ingested. Acute soluble barium poisoning is an uncommon but life-threatening problem. The fatal dose of barium chloride for man has been reported to be only 0.8 to 0.9 gram. Currently, there have been no systematic studies on acute soluble barium poisoning. Based on the retrospective analysis of 55 global cases, toxicological characteristics, clinical features and management of acute soluble barium poisoning were summarized. Barium is a competitive blocker of potassium inward rectifier channels to inhibit K+ efflux, resulting in profound hypokalemia. Acute soluble barium poisoning can result in gastrointestinal effects including vomiting and diarrhea, followed by hemodynamic disturbances, cardiac arrhythmias, muscle weakness, and cardiac arrest. Respiratory failure induced by muscle paralysis is the major cause of death. Management strategies mainly include prevention of barium absorption, administration of soluble sulfates, potassium supplementation, antiarrhythmic medications, hemodialysis/CVVHDF, and cardiorespiratory support. Timely administration of decontamination and correction of hypokalemia are the two important points. This narrative review will offer crucial information for treating patients with acute soluble barium poisoning.

Non-fatal acute barium carbonate poisoning following suicidal ingestion: A case report

Acute barium poisoning is a rare but life-threatening method of suicide attempt, and it is a challenging disease in the emergency department. We report a case of barium carbonate poisoning in a 21-year-old man who ingested a large dose to attempt suicide and presented with gastrointestinal symptoms, gradual muscular weakness, and severe hypokalemia (K+1.63 mmol/L). He was promptly managed with gastric lavage, respiratory support, and large doses of oral and intravenous potassium supplementation. In addition, intravenous sodium thiosulfate and continuous venovenous hemodiafiltration were administered to reduce the serum concentration of barium ions. Following comprehensive treatment, the patient recovered within 5 days and discharged home for 12 days. Clinicians should be vigilant when a patient presents gastrointestinal symptoms and limb weakness, associated with severe hypokalemia and cardiac arrhythmia over a short disease course as these may indicate potential barium poisoning. Furthermore, we advocate for paying more attention to the management of toxic substances and the mental health education of young adults.

Suicide by an Unusual Compound: A Case of Barium Acetate Toxicity

ABSTRACT

Forensic pathologists may sometimes encounter cases of suicide with ingestion of unusual compounds. Herein, we describe a case of suicide by ingestion of barium acetate. Deaths by ingestion of this compound have not previously been reported in literature. This case shows the clinical presentation of the toxicity of barium compounds and highlights the importance of scene investigation and clinicopathologic correlation in suicides by unusual ingestion.

An unwitnessed case of foreign body aspiration of barium from an unknown source

Foreign body (FB) aspiration is potentially life-threatening in children. A variety of sources and objects have been noted in aspiration events with possible complications ranging from mild to life-threatening. While rare, barium aspiration can cause severe complications, and removal is particularly challenging. Complications of retained barium include acute respiratory distress syndrome, pneumonitis, sepsis, even death. Regardless of the foreign body's identity, substance removal is critical in management. Resourcefulness of removal techniques and an interdisciplinary approach may allow for maximally effective management. We present a case of a pediatric barium aspiration from an unknown source and review evaluation and management strategies.

Low dialysate potassium concentration: an overrated risk factor for cardiac arrhythmia?

Serum potassium concentrations rise with dietary potassium intake between dialysis sessions and are often at hyperkalemic levels by the next session. Conversely, potassium concentrations fall during each hemodialysis, and sometimes reach hypokalemic levels by the end. Low potassium dialysate, which rapidly decreases serum potassium and often brings it to hypokalemic levels, is almost universally considered a risk factor for life-threatening arrhythmias. While there is little doubt about the threat of lethal arrhythmias due to hyperkalemia, convincing evidence for the danger of low potassium dialysate and rapid or excess potassium removal has not been forthcoming. The original report of more frequent ventricular ectopy in early dialysis that was improved by reducing potassium removal has received very little confirmation from subsequent studies. Furthermore, the occurrence of ventricular ectopy during dialysis does not appear to predict mortality. Studies relating sudden deaths to low potassium dialysate are countered by studies with more thorough adjustment for markers of poor health. Dialysate potassium concentrations affect the excursions of serum potassium levels above or below the normal range, and have the potential to influence dialysis safety. Controlled studies of different dialysate potassium concentration and their effect on mortality and cardiac arrests have not been done. Until these results become available, I propose interim guidelines for the setting of dialysate potassium levels that may better balance risks and benefits.

Fatal barium chloride poisoning: four cases report and literature review

Barium is an alkaline earth metal which has a variety of uses including in the manufacturing industry and in medicine. However, adverse health effects and fatalities occur due to absorption of soluble barium compounds, notably the chloride, nitrate, and hydroxide, which are toxic to humans. Although rare, accidental and suicidal modes of poisoning are sporadically reported in the literature.We describe 4 cases of poisoning due to barium chloride in China. In witnessed cases, severe gastrointestinal symptoms, hypokalemia leading to muscle weakness, cardiac arrhythmias, and respiratory failure were noted. Autopsy showed some nonspecific but common findings, such as subendocardial hemorrhage in the ventricles, visceral petechiae, and fatty changes in the liver. Interestingly, microscopic examination showed degenerative changes and amorphous, flocculent foamy materials in the renal tubules. Toxicology was relevant for barium in blood and tissues. Three of the cases were accidental and 1 homicidal in nature. A round-up of relevant literature on fatal barium compounds poisoning is also provided. Forensic pathologists should be aware of the clinical presentations of barium compound poisoning and especially look for any evidence of hypokalemia. Still, postmortem toxicological and histological studies are essential for an accurate identification of the cause of death.

Application of ICP-OES to the determination of barium in blood and urine in clinical and forensic analysis

Exposure to barium (Ba) mostly occurs in the workplace or from drinking water, but it may sometimes be due to accidental or intentional intoxication. This paper presents a reliable, sensitive method for the determination of Ba in blood and urine: inductively coupled plasma optical emission spectrometry (ICP-OES) after microwave digestion of samples. The overall procedure was checked using Seronorm Whole Blood L-2, Trace Elements Urine and spiked blood and urine samples (0.5-10 µg/mL of Ba). The accuracy of the whole procedure (relative error) was 4% (blood) and 7% (urine); the recovery was 76-104% (blood) and 85-101% (urine). The limits of detection and quantification (Ba λ = 455.403 nm) were 0.11 and 0.4 µg/L of Ba, respectively; precision (relative standard deviation) was below 6% at the level of 15 µg/L of Ba for blood. This method was applied to a case of the poisoning of a man who had been exposed at the workplace for over two years to powdered BaCO3, and who suffered from paralysis and heart disorders. The concentrations of Ba, in μg/L, were 160 (blood), 460 (serum) and 1,458 (urine) upon his admission to the hospital, and 6.1 (blood) and 4.9 (urine) after 11 months (reference values: 3.34 ± 2.20 µg/L of Ba for blood and 4.43 ± 4.60 µg/L of Ba for urine).

Intoxication by large amounts of barium nitrate overcome by early massive K supplementation and oral administration of magnesium sulphate

Suicide by ingestion of barium is exceptionally rare. Adverse health effects depend on the solubility of the barium compound. Severe hypokalemia, which generally occurs within 2 hours after ingestion, is the predominating feature of acute barium toxicity, subsequently leading to adverse effects on muscular activity and cardiac automaticity. We report one case of acute poisoning with barium nitrate, a soluble barium compound. A 75-year-old woman was hospitalized after suicidal ingestion of a burrow mole fumigant containing 12.375 g of barium nitrate. About 1 hour post-ingestion, she was only complaining of abdominal pain. The ECG recording demonstrated polymorphic ventricular premature complexes (VPCs). Laboratory data revealed profound hypokalemia (2.1 mmol/L). She made a complete and uneventful recovery after early and massive potassium supplementation combined with oral magnesium sulphate to prevent barium nitrate absorption.

Acute barium toxicity from ingestion of "snake" fireworks

INTRODUCTION

Ingestion of fireworks has been infrequently reported in the medical literature. We describe a case of acute barium poisoning following firework ingestion.

CASE REPORT

A 35-year-old male with a history of severe mental retardation presented with vomiting and diarrhea following ingestion of 16 small fireworks ("color snakes" and "black snakes"). His condition rapidly deteriorated and he developed obtundation, wide complex dysrhythmias, and respiratory failure. Approximately 12 hours following ingestion, his serum potassium level was 1.5 mmol/L with a serum barium level of 20,200 microg/mL (reference range <200 microg/L). The patient eventually recovered with ventilatory support and potassium supplementation.

DISCUSSION

Although firework ingestion is uncommon, clinicians should be prepared for potentially severe complications. In the case of barium poisoning, treatment consists of potassium supplementation, along with respiratory and hemodynamic support.

Mass barium carbonate poisoning with fatal outcome, lessons learned: a case series

INTRODUCTION

Barium, a heavy divalent alkaline metal, has long been known to cause human toxicity. The common mode is accidental ingestion and the common compound is Barium carbonate. Here we report an incident of food poisoning in 27 law enforcement personnel with rapidly developing sequelae and a high mortality due to ingestion of Barium carbonate contaminated flour.

CASE PRESENTATION

One midnight, 27 adult males were rushed to emergency department of Chittagong Medical College Hospital with abdominal pain, vomiting, loose motion, cramps and generalized paraesthesia. The ailment started 1-2 hours after Iftar (evening meal to break day long fast during Ramadan) which included fried vegetables coated with a flour paste. On admission, twenty of them were restless, agitated. 22 reported weakness of limbs and were unable to walk. 10 had hypotension. 22 had rapid and shallow respiration. 5 had carpopedal spasm. Different grades of limb weakness were noted with loss of tendon jerks. Ten (N12) patients had hypokalaemia, three had hypoglycaemia, 4 patients had high creatine kinase. Electrocardiogram showed flat ST with U waves in 4 patients. Potassium containing intravenous fluid and Oxygen was administered. Due to limited availability of mechanical ventilators patients were put on artificial respiration using Ambu bag; manually maintained by doctors, paramedics and attendants. Four patients were transferred to another hospital for mechanical ventilation. A total of 12 patients died over next 16 hours, 4 within 3 hrs. Other patients gradually improved. Chemical analysis of the vomitus, blood and flour used for preparation of meal revealed the presence of Barium. It was assumed that the flour was contaminated with the similar looking Barium carbonate powder which was kept in the kitchen as a rodenticide.

CONCLUSION

This event exemplifies the weakness of usual health care facility in resource poor settings to cope with this kind of massive poisoning event. The multiple reported incidences of accidental Barium poisoning due to unintentional mixing with food signifies the fact that the use and availability of Barium carbonate should be restricted. We hope to draw attention to this relatively uncommon poisoning and to the need for development of poison information centre in resource poor countries.

Mass barium carbonate poisoning with fatal outcome, lessons learned: a case series

INTRODUCTION

Barium, a heavy divalent alkaline metal, has long been known to cause human toxicity. The common mode is accidental ingestion and the common compound is Barium carbonate. Here we report an incident of food poisoning in 27 law enforcement personnel with rapidly developing sequelae and a high mortality due to ingestion of Barium carbonate contaminated flour.

CASE PRESENTATION

One midnight, 27 adult males were rushed to emergency department of Chittagong Medical College Hospital with abdominal pain, vomiting, loose motion, cramps and generalized paraesthesia. The ailment started 1-2 hours after Iftar (evening meal to break day long fast during Ramadan) which included fried vegetables coated with a flour paste. On admission, twenty of them were restless, agitated. 22 reported weakness of limbs and were unable to walk. 10 had hypotension. 22 had rapid and shallow respiration. 5 had carpopedal spasm. Different grades of limb weakness were noted with loss of tendon jerks. Ten (N12) patients had hypokalaemia, three had hypoglycaemia, 4 patients had high creatine kinase. ECG showed flat ST with U waves in 4 patients. Potassium containing intravenous fluid and Oxygen was administered. Due to limited availability of mechanical ventilators patients were put on artificial respiration using Ambu bag; manually maintained by doctors, paramedics and attendants. Four patients were transferred to another hospital for mechanical ventilation. A total of 12 patients died over next 16 hours, 4 within 3 hrs. Other patients gradually improved. Chemical analysis of the vomitus, blood and flour used for preparation of meal revealed the presence of Barium. It was assumed that the flour was contaminated with the similar looking Barium carbonate powder which was kept in the kitchen as a rodenticide.

CONCLUSION

This event exemplifies the weakness of usual health care facility in resource poor settings to cope with this kind of massive poisoning event. The multiple reported incidences of accidental barium poisoning due to unintentional mixing with food signifies the fact that the use and availability of barium carbonate should be restricted. We hope to draw attention to this relatively uncommon poisoning and to the need for development of poison information centre in resource poor countries.

Acute barium nitrate intoxication treated by hemodialysis

A 22-year-old male was admitted to hospital with diarrhea and vomiting, cardiac arrhythmias, severe hypokalemia and gradual onset of muscular weakness. A potassium infusion was started, but for several hours serum potassium remained low. Evidence of toxic ingestion was initially lacking. When it became clear -- after a considerable delay -- that the patient had ingested barium nitrate, hemodialysis was started. This resulted in rapid clinical improvement with correction of hypokalemia and restored muscular function. Intoxication with barium causes hypokalemia, arrhythmias, muscular weakness and paralysis, often requiring respiratory support. This patient presented with symptoms typical of severe barium intoxication, non-responsive to potassium supplementation. There are few published reports on the use of hemodialysis in barium poisoning. This case confirms the possible benefit of hemodialysis in severe cases, where potassium supplementation alone is insufficient.

Acute Hypercapnic Respiratory Failure due to Thyrotoxic Periodic Paralysis

Acute hypercapnic respiratory failure is a potentially life-threatening complication of profound hypokalemia usually seen in patients with large total-body potassium (K+) deficits. It has rarely been reported in thyrotoxic periodic paralysis (TPP), which is due to intra-cellular shifts of K+. The authors report on a 29-year-old man who presented with sudden onset of muscle paralysis in all extremities and acute progressive respiratory insufficiency requiring artificial respiratory support. He was treated with intravenous KCl. After six hours, muscular strength had returned to normal, with plasma K+ concentration of 3.0 mmol/L. At the eighth hour, rebound hyperkalemia (6.6 mmol/L) developed with high-tented T waves, even after the KCl was discontinued. Ventilatory support was uneventfully weaned at 14 hours. Elevated free thyroxine and undetectable thyroid-stimulating hormone confirmed the diagnosis of TPP. TPP should be kept in mind as a cause of acute respiratory failure in association with acute muscle weakness to avoid delayed diagnosis and improper management.

Acute barium intoxication and hemodiafiltration

We report a case of severe hypokalemia and flaccid muscle paralysis following a suicide attempt associating the calcium channel blocker amlodipine, the antidepressant fluoxetine and barium carbonate. Despite rapid correction of severe, life-threatening hypokalemia, areflexic quadriplegia persisted, suggesting a direct effect of barium on muscle cells. Continuous veno-venous hemodiafiltration (CVVHDF) was initiated. We determined barium concentration in the urine, plasma, and hemodiafiltrate during CVVHDF. We subsequently calculated the amounts of barium eliminated both by the CVVHDF and the kidneys. CVVHDF triples the measured barium elimination, reduced serum barium half-life by a factor of three, stabilized serum potassium levels, and rapidly improved motor strength, with complete neurological recovery within 24 h. Presentation and treatment of barium intoxication are discussed.

Poisoning as a result of barium styphnate explosion

BACKGROUND

Acute barium poisoning is most often the result of accidental or suicidal ingestion of the rodenticide, barium carbonate. We describe a trauma patient whose condition was complicated by severe acute barium toxicity from an explosion of the propellant, barium styphnate. In addition to critical injuries, the patient manifested classic signs of barium toxicity including repeated profound hypokalemia, cardiac arrhythmias, respiratory failure, prolonged gastrointestinal dysfunction, paralysis, myoclonus, hypertension, and profound lactic acidosis.

METHODS

The patient required lidocaine for ventricular bigeminy, massive infusions of potassium, prolonged ventilatory support, and parenteral nutrition to manage the effects of barium toxicity.

RESULTS

He is the first reported case to demonstrate recurrent profound hypokalemia as an effect of blood transfusions.

CONCLUSIONS

Considering the paucity of information concerning management of this life-threatening problem, the pathophysiology of barium toxicity, including the transfusion related hypokalemia, and its management is reviewed.

Suicidal poisoning with barium chloride

A 49-year-old male pharmacist suffering from depression phoned the emergency services telling of how he had ingested barium chloride. He was found semicomatose in bed and resuscitation attempts were to no avail and he died at the scene. A white plastic container labelled "Barium chloride... Poison", and a book with a writing on a blank page... "give sulphate... SO(4)" were found. At autopsy, 1l of whitish-yellow fluid was found in the stomach. Autopsy barium levels were: blood 9.9mg/l; bile 8.8mg/l; urine 6.3mg/l; gastric 10.0g/l. Cause of death was given as cardiorespiratory arrest due to barium chloride poisoning. The issue of barium toxicity in a variety of itatrogenic and non itatrogenic situation is discussed together with the two only other cases of suicidal barium ingestion, and the feasibility of early intervention at the scene by an emergency team.

Hypokalemic muscular paralysis causing acute respiratory failure due to rhabdomyolysis with renal tubular acidosis in a chronic glue sniffer

CASE REPORT

A 34-year-old male was admitted to the emergency department with the development of quadriparesis and respiratory failure due to hypokalemia after prolonged glue sniffing. The patient was subsequently given mechanical ventilatory support for respiratory failure. He was weaned from the ventilator 4 days later after potassium replacement. Toluene is an aromatic hydrocarbon found in glues, cements, and solvents. It is known to be toxic to the nervous system, hematopoietic system, and causes acid-base and electrolyte disorders. Acute respiratory failure with hypokalemia and rhabdomyolysis with acute renal failure should be considered as potential events in a protracted glue sniffing.

Acute barium intoxication following ingestion of ceramic glaze

A case of deliberate overdose of barium sulphide in a psychiatric setting is presented, with resulting flaccid paralysis, malignant arrhythmia, respiratory arrest and severe hypokalaemia, but ultimately with complete recovery. The degree of paralysis appears to be related directly to serum barium levels. The value of early haemodialysis, particularly with respiratory paralysis and hypokalaemia, is emphasised.

Effect of replacement of the tightly bound Ca2+ by Ba2+ on actin polymerization

G-actin has a single tight-binding (high-affinity) site for divalent cations per mole of protein, whose occupancy is important for the stability of the molecule. Different tightly bound divalent cations differently influence the polymerization properties of actin. The tightly bound metal ion easily exchanges for free exogenous cations. Moreover, biochemical and structural evidence demonstrates that actin, in both the G- and F-forms, assumes different conformations depending on the metal ion bound with high affinity in the cleft between two main domains of the molecule. In this work, we used proteolytic susceptibility to detect possible local conformational alterations of the actin molecule following a brief incubation of Ca-G-actin with barium chloride and ethylene glycol-bis(beta-aminoethyl ether)-N,N,N',N'-tetraacetic acid. We found that substitution of Ba2+ for the tightly bound Ca2+ affects the regions around Arg-62 and Lys-68 in subdomain 2 of G-actin, as judged from inhibition of tryptic cleavage at these residues. Using the fluorescent chelator Quin-2, we observed that about 0.95 mol of Ba2+ is released per 1 mol of actin. We also examined the effect of replacement of the tightly bound Ca2+ by Ba2+ on actin polymerization. With respect to Ca-actin, Ba-actin shows an increased polymerization rate, mainly due to its enhanced nucleation and a higher critical concentration.

Preliminary assessment of potential health hazards associated with barium leached from glazed ceramicware

Ceramic glazes contain several elements which have the potential to leach into food or beverages that are held or stored in ceramicware. Recently, barium salts have been investigated as one of the alternatives to lead in frit formulations for glazes. This preliminary evaluation addresses the potential health hazards associated with barium at levels that might leach from glazed ceramicware. A set of specialty ceramicware, consisting of five teacups and a pitcher, was examined for extractable barium. Exposure to barium that adults (18-44 years) might encounter using the vessels for coffee, tea, or orange juice was estimated. The exposure estimate was derived from values for intakes of the beverages and for the barium migration from glazed ceramicware test samples. An established reference dose (RfD) for barium exposure for the critical effect of hypertension was identified. The potential hazard associated with the leaching of barium from glazed ceramicware varied with the level of use. Consuming beverages in amounts up to the 95th percentile would not result in total barium intake in amounts that exceed the RfD; consuming large quantities (> 95th percentile) of beverages such as tea or coffee from glazed vessels might. This suggests that for a small portion of the population of users, intake of barium may be in quantities that warrant further consideration as a potential health hazard. Analyses of a broad sample of ceramicware and study of barium leaching behaviour under actual use conditions are needed to assess further the significance of these findings.

Disturbances of potassium homeostasis in poisoning

Unless renal function is impaired or rhabdomyolysis is severe, hyperkalemia is a relatively uncommon metabolic complication of poisoning. In contrast, marked hypokalemia is a more common problem and may have serious sequelae. Most potassium disturbances in acute poisoning are due to disruption of extra-renal control mechanisms, notably the activity of Na+/K+ ATPase and K+ channels. Hypokalemia occurs because of increased Na+/K+ ATPase activity (e.g. beta 2 agonist, theophylline or insulin poisoning), competitive blockade of K+ channels (e.g. barium or chloroquine poisoning), gastrointestinal losses and/or alkalosis. Hyperkalemia follows inhibition of Na+/K+ ATPase activity (e.g. by digoxin), increased uptake of potassium salts, disruption of intermediary metabolism (e.g. cyanide poisoning), activation of K+ channels (e.g. fluoride poisoning), and the presence of acidosis and rhabdomyolysis, particularly if the latter is complicated by renal failure. Hypokalemia results in generalized muscle weakness, paralytic ileus, ECG changes (flat or inverted T waves, prominent U waves, ST segment depression) and cardiac arrhythmias (atrial tachycardia +/- block, AV dissociation, VT, VF). Hyperkalemia is associated with abdominal pain, diarrhea, muscle pain and weakness, ECG changes (tall peaked T waves, ST segment depression, prolonged PR interval, QRS prolongation) and cardiac arrhythmias (VT, VF). Significant disturbances of potassium homeostasis are often unrecognized and may cause considerable morbidity and mortality. Prompt recognition and appropriate treatment of these disturbances could be life-saving.

[Voluntary barium poisoning]

A 45-year-old man attempted to commit suicide by ingesting a large amount of barium. In some hours, he experienced generalized muscle weakness with hypokalaemia, treated by large dose of potassium (440 mmol in the first day). This weakness resulted in difficulties in swallowing and respiratory failure requiring mechanical ventilation. An anuric renal insufficiency started early, requiring haemodialysis for three weeks. It was induced probably by renal toxicity of barium and recovered completely. Later, the patient experienced an extrapyramidal syndrome initiated by tremor and myoclonia. Hypertonia induced a parkinsonian rheumatism, fixing the two hands in an irreducible position. There was also a contracture of superior sphincter of oesophagus, with severe disturbance of deglutition, ending after three months only. MRI study showed a bilateral hypersignal in basal ganglia and thalamus. It remains unknown whether this neurological syndrome was toxic or ischaemic. This patient remained under mechanical ventilation for three months because of disturbances of deglutition. He was discharged to his home at the 6th month. One year later he was still adynamic, but able to carry our rather precise movements.