Barium Toxicity

Aka: Barium Toxicity, Barium Poisoning

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II. Background

  1. Barium is an alkaline Heavy Metal with atomic number 56
  2. Barium is found in nature primarily in 2 salt forms (but not in elemental state)
    1. Barium Sulfate (barite)
    2. Barium carbonate (witherite, highest toxicity risk)
  3. Barium commerical uses
    1. Medical Imaging (radiocontrast)
      1. Barium Enema
      2. Barium swallow
    2. Manufacturing
      1. Pigment or textile dye
      2. Ceramic, glass or Rubber production
      3. Depilatory
    3. Miscellaneous
      1. Rodenticide
      2. Insecticide
  4. Background low level exposure
    1. Drinking water
    2. Foods (nuts, seaweed, fish)

III. Mechanism

  1. Toxicity (typically by barium salt ingestion)
    1. Intracellular Potassium shift (Hypokalemia, Muscle depolarization, paralysis)
    2. Vascular Potassium channel inhibition (Vasoconstriction, Hypertension, Lactic Acidosis)

IV. Pharmacokinetics

  1. Absorption: 5-10% of ingested barium salt
  2. Peak serum level after ingestion: 2 hours
  3. Elimination: Hepatic 75%, Renal 25%
  4. Half-Life: 18 to 85 hours

V. Findings

  1. Gastrointestinal
    1. Abdominal Pain
    2. Nausea and Vomiting
    3. Diarrhea
  2. Cardiopulmonary
    1. Acute Respiratory Failure (related to Hypokalemia and paralysis)
    2. Hypertension
    3. Dysrhythmia
  3. Neurologic
    1. Muscle Weakness progressing to Flaccid Paralysis
    2. Rhabdomyolysis
    3. Seizures
    4. Altered Mental Status
  4. Metabolic
    1. Hypokalemia
    2. Hypophosphatemia
    3. Lactic Acidosis

VI. Labs

  1. See Unknown Ingestion
  2. Chemistry Panel
    1. Serum Creatinine
    2. Serum Potassium
      1. Serum Potassium <3 mEq/L at 2 hours after ingestion is a marker of severe Barium Poisoning
  3. Serum Phosphorus
  4. Venous Blood Gas

VII. Diagnostics

  1. Electrocardiogram

VIII. Imaging

  1. Abdominal XRay
    1. Barium is radiopaque

IX. Management

  1. ABC Management
  2. Decontamination
    1. Orogastric Lavage if massive ingestion presentation within 1 hour OR
    2. Magnesium Sulfate 20 grams orally
  3. Hypokalemia management
    1. Aggressive Potassium Replacement
    2. Potassium Replacement requirements may exceed 400 mEq/day
    3. Consider Hemodialysis for persistent Hypokalemia or weakness
  4. Respiratory Failure management
    1. Endotracheal Intubation and Mechanical Ventilation
  5. Disposition
    1. Asymptomatic patients with normal Serum Potassium at 6 hours may be discharged home
    2. Admit symptomatic patients (typically ICU)

X. References

  1. Carroll and Yakey (2025) Crit Dec Emerg Med 39(9): 34
  2. Su (2020) Chin Med J 133(6):724-5 +PMID: 32068602 [PubMed]
  3. Jamshidi (2022) Clin Toxicol 60(8):974-8 +PMID: 35506754 [PubMed]
  4. Bhoelan (2014) Clin Toxicol 52(6):584-93 +PMID: 24905573 [PubMed]

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