The Poison Review

ACUTE BARIUM TOXICITY FROM INGESTION OF “SNAKE” FIREWORKS. Rhyee SH, Heard K. J Med Toxicol Dec 2009;5:209-213.

Abstract

This very interesting case report describes a 35-year-old male nursing home patient who presented to the emergency department with vomiting and diarrhea after ingesting 16 “color snakes” and “black snakes” fireworks.  He developed  hypokalemia, wide-complex cardiac dysrhythmias, self-limiting episodes of ventricular tachycardia and hypotension, muscle weakness, and respiratory failure.  Because of severe and persistent hypokalemia, barium toxicity was suspected and later confirmed by measuring serum and spot urine levels. The authors note that barium chlorate is often added to fireworks to produce green color on ignition.

The classic triad of barium toxicity includes gastronintestinal symptoms, motor weakness, and extreme hypokalemia. Barium interferes with potassium transport, causing intracellular sequestion of the ion and severe hypokalemia without total body loss.  Effects of hypokalemia include cardiac instability, muscle weakness, and respiratory failure.  Barium sulfate, which is not soluble in water, is harmless when ingested. The authors make the following points about barium toxicity:

• Despite the occurence of wide-complex dysrhythmias, IV bicarbonate is contraindicated in known barium poisoning because it will exacerbate hypokalemia.

• Early after barium ingestion, oral (not IV) magnesium sulfate might be beneficial since it forms insoluble barium sulfate.

• Treatment of barium poisoning begins with good supportive care and repletion of potassium. In severe cases,  hemodialysis can be considered to enhance elimination of barium and correct hypokalemia.

• Although aggresive potassium repletion is indicated, potassium levels have to be followed closely since rebound can occur.

• Barium salts are radio-opaque and may be seen on an abdominal x-ray.