(843) Profound Hypokalemia Following Barium Containing "Snake" Firework Ingestion in a Pediatric Patient

Sunday, February 23, 2025

2:30pm – 3:30pm Eastern Time

Location: Connections Central - RST 05

First Author(s)

SJ

Sneha Jayadeep, MBBS (she/her/hers)

North Little Rock, Arkansas, USA

Co-Author(s)

WF

William T Fisher, MD

Pediatric Resident
University of Arkansas for Medical Sciences, United States
RM

Rebecca J J. Martin, MD

Pediatric Critical Care Fellow
University of Arkansas for Medical Sciences, United States
SR

Saritha Ranabothu, MD

Associate Professor, Pediatric Nephrology
University of Arkansas for Medical Sciences, United States
SP

Sanjiv Pasala, MD

Associate Professor, Pediatric Critical Care Medicine
University of Arkansas for Medical Sciences, Arkansas, United States
AF

Ari B Filip, MD

Assistant Professor, Clinical Pharmacology and Toxicology
University of Arkansas for Medical Sciences, United States

Introduction: Barium poisoning is uncommon but may be life-threatening. Once absorbed, barium ions interfere with potassium transport causing intracellular sequestration and severe hypokalemia. We present a case of profound hypokalemia after ingestion of barium-containing “snake” fireworks.

Description: A 16-year-old female with trisomy 21 presented with abdominal pain, vomiting, and dark pellets in stools. She had profound hypokalemia (potassium 1.4 mEq/L), acute kidney injury, and leukocytosis. CT showed multiple metallic densities in the distal ileum and cecum, suspected to be snake fireworks. EKG demonstrated QTc of 608ms. She had worsening weakness and hypercarbic respiratory failure requiring intubation. She received IV potassium replacement and was transferred to the pediatric ICU for emergent hemodialysis. In the PICU, she remained hypokalemic (potassium 1.4 mEq/L). Additional labs, such as magnesium, complete blood count, and coagulation factors were within normal limits. Emergent hemodialysis was initiated, followed by continuous renal replacement therapy (CRRT) for enhanced barium elimination and electrolyte correction. She received whole bowel irrigation with magnesium sulfate via nasogastric tube to bind residual enteric barium and enhance catharsis. Within 24 hours of admission, hypokalemia resolved and QTc interval normalized. CRRT was discontinued without rebound hyperkalemia. Physical exam showed sustained bilateral clonus on hospital day 2 which resolved by hospital day 4. She was discharged without sequelae on hospital day 6. Serum barium testing, collected on admission, later resulted at 2900 mcg/L.

Discussion: Barium poisoning is part of a broad differential for the nonspecific symptoms of abdominal pain, vomiting, and weakness, and may be easily missed. Physicians should be vigilant to the diagnosis of barium poisoning in patients with severe, unexplained hypokalemia. Timely diagnosis and prompt administration of potassium supplementation are lifesaving. Given its low molecular weight, volume of distribution, and low protein binding, we encourage early dialysis, especially in those not responsive to potassium replacement. Pediatricians should have a high index of suspicion for accidental ingestions, especially in patients with intellectual disability.