1) Monitor serum potassium and correct as necessary. Administer intravenous fluids to maintain urine.
B) MANAGEMENT OF SEVERE TOXICITY
1) Profound hypokalemia may develop rapidly, causing profound weakness, respiratory insufficiency, and dysrhythmias. Monitor for weakness and respiratory insufficiency, manage airway early. Monitor serial serum potassium and correct aggressively. Dysrhythmias are usually secondary to hypokalemia and generally respond to potassium administration. Administer intravenous fluids to maintain adequate urine output. Hemodialysis should be performed in patients with severe hypokalemia, severe weakness, or ventricular dysrhythmias that are not responding to potassium supplementation.
C) DECONTAMINATION
1) Activated charcoal likely ineffective in adsorbing barium. Consider insertion of a nasogastric tube to aspirate gastric contents, or gastric lavage, in patients with recent ingestion who can protect their airway or who are intubated.
2) Wash exposed skin with soap and water. Remove contaminated clothing.
D) AIRWAY MANAGEMENT
1) Severe hypokalemia may result in respiratory muscle weakness and respiratory failure. Monitor adequacy of respirations, and manage airway early if necessary.
E) MAGNESIUM SULFATE
1) Magnesium sulfate when given orally results in the formation of nonabsorbable barium sulfate within the gastrointestinal tract. Dose: 250 mg/kg for children and 30 g for adults. Sodium sulfate is an alternative. ADULT: 30 g in 250 ml water orally.
F) HYPOKALEMIA
1) Profound hypokalemia can develop rapidly. Aggressive supplementation, both orally and intravenously, is the mainstay of therapy.
G) DYSRHYTHMIAS
1) Dysrhythmias are usually secondary to hypokalemia. Aggressive intravenous and oral potassium supplementation is the mainstay of treatment. Antidysrhythmics such as lidocaine or amiodarone may be used, but efficacy may be limited in patients with persistent hypokalemia.
H) HEMODIALYSIS
1) Hemodialysis is effective (corrects hypokalemia, and associated weakness and dysrhythmias, enhances barium elimination) in patients with severe poisoning. It should be considered early in patients with hypokalemia, severe weakness or dysrhythmias that are not responding to potassium supplementation.
I) PATIENT DISPOSITION
1) OBSERVATION CRITERIA: All patients who have ingested a soluble barium salt should be sent to a healthcare facility for evaluation and treatment. Patients should be observed for 6 to 8 hours with ECG monitoring, serial serum potassium concentrations, and evaluation for weakness. Patients who are asymptomatic with normal serum potassium during 6 to 8 hours of observation may be discharged.
2) ADMISSION CRITERIA: Patients with hypokalemia, weakness or dysrhythmias should be admitted to an intensive care setting for cardiac, respiratory and neurologic monitoring and aggressive potassium replacement.
3) CONSULT CRITERIA: Consult a medical toxicologist and/or poison center for any patient with significant barium poisoning or in whom the diagnosis is unclear. Consult a nephrologist for emergent dialysis in any patients with severe poisoning.
J) PITFALLS
1) Inadequate monitoring for weakness, respiratory insufficiency, hypokalemia, dysrhythmias.
2) Since barium does not decrease total body potassium, but rather shifts it intracellularly; hyperkalemia may develop once barium toxicity has resolved.
K) TOXICOKINETICS
1) Rapidly absorbed, primarily fecal elimination. Half life 18 hours (based on single case report).
Rumack BH POISINDEX(R) Information System Micromedex, Inc., Englewood, CO, 2017; CCIS Volume 172, edition expires May, 2017. Hall AH & Rumack BH (Eds): TOMES(R) Information System Micromedex, Inc., Englewood, CO, 2017; CCIS Volume 172, edition expires May, 2017.
0.4.2 ORAL EXPOSURE
A) MANAGEMENT OF MILD TO MODERATE TOXICITY
1) Treatment consists primarily of symptomatic and supportive care. Monitor for respiratory distress and systemic toxicity. Early gastrointestinal endoscopy to evaluate for burns. Endoscopy should be performed within the first 24 hours postingestion (preferably within 12 hours), and should be avoided from 2 days to 2 weeks postingestion since wound tensile strength is lowest and the risk of perforation highest during this time. Dilution with milk or water may be cautiously recommended. If a patient can protect their airway, immediately dilute with 4 to 8 ounces (120 to 240 mL) of water or milk (not to exceed 4 ounces/120 mL in a child). However, some clinicians have had experience with precipitation of vomiting from dilution. For a large recent ingestion, consider inserting a small flexible nasogastric tube and aspirate stomach contents. Manage mild hypotension with IV fluids.
B) MANAGEMENT OF SEVERE TOXICITY
1) Treatment consists primarily of symptomatic and supportive care. Treat severe hypotension with IV 0.9% NaCl at 10 to 20 mL/kg. Add dopamine or norepinephrine if unresponsive to fluids. In patients with respiratory distress or dyspnea, administer 100% humidified supplemental oxygen, perform endotracheal intubation and provide assisted ventilation as required. Administer inhaled beta-2 adrenergic agonists if bronchospasm develops. Obtain a methemoglobin level in cyanotic patients. Treat symptomatic methemoglobinemia (usually at methemoglobin levels above 20% to 30%) with methylene blue and oxygen therapy. N-acetylcysteine has been used in the treatment of potassium permanganate induced hepatotoxicity, but efficacy has not been established. Monitor blood manganese level in patients with chronic potassium permanganate ingestion who have abnormal neurologic symptoms. Chelation with EDTA and sodium para-aminosalicylic acid has been used in patients with manganese intoxication. However, there is no experience with potassium permanganate exposure and the effectiveness of chelation treatment in improving existing neurological findings or preventing neurologic deterioration has not been clearly demonstrated.
C) DECONTAMINATION
1) ORAL EXPOSURE: The role of gastric decontamination is unclear. Due to the irritant nature of this substance, do not induce vomiting. Neutralization, gastric lavage, and activated charcoal are all contraindicated. In patients without vomiting or respiratory distress who are able to swallow, dilute with milk/water shortly after ingestion; then NPO until after endoscopy. EYE EXPOSURE: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water until pH is neutral. If irritation, pain, swelling, lacrimation, or photophobia persists after 15 minutes of irrigation, an ophthalmologic examination should be performed. DERMAL EXPOSURE: Remove contaminated clothes, brush off particulate corrosives, follow with copious irrigation. A physician may need to examine the area if irritation or pain persists. INHALATIONAL EXPOSURE: Move patient to fresh air. Monitor for respiratory distress. If cough or difficulty breathing develops, evaluate for respiratory tract irritation, bronchitis, or pneumonitis. Administer 100% humidified supplemental oxygen. Administer inhaled beta adrenergic agonists if bronchospasm develops.
D) ENDOSCOPIC PROCEDURE
1) Endoscopy should be performed within the first 24 hours postingestion (preferably within 12 hours), and should be avoided from 2 days to 2 weeks postingestion since wound tensile strength is lowest and the risk of perforation highest during this time. Endoscopy should be performed in any patient with deliberate ingestion, adults with any signs or symptoms attributable to inadvertent ingestion, and in children with stridor, vomiting, or drooling after inadvertent ingestion. Endoscopy should also be considered in children with dysphagia or refusal to swallow, significant oral burns, or abdominal pain after unintentional ingestion. Children and adults who are asymptomatic after inadvertent ingestion do not require endoscopy. The grade of mucosal injury at endoscopy is the strongest predictive factor for the occurrence of systemic and GI complications and mortality. The absence of visible oral burns does NOT reliably exclude the presence of esophageal burns. If second or third degree burns are found, follow 10 to 20 days later with barium swallow or esophagram.
E) AIRWAY MANAGEMENT
1) Ensure adequate ventilation and perform endotracheal intubation early in patients with upper airway injury.
F) ANTIDOTE
1) Treat symptomatic methemoglobinemia (usually at methemoglobin levels above 20% to 30%) with methylene blue. N-acetylcysteine has been used in the treatment of potassium permanganate induced hepatotoxicity, but efficacy has not been established.
G) METHEMOGLOBINEMIA
1) Initiate oxygen therapy. Treat with methylene blue if patient is symptomatic (usually at methemoglobin concentrations greater than 20% to 30% or at lower concentrations in patients with anemia, underlying pulmonary or cardiovascular disease). METHYLENE BLUE: INITIAL DOSE/ADULT OR CHILD: 1 mg/kg IV over 5 to 30 minutes; a repeat dose of up to 1 mg/kg may be given 1 hour after the first dose if methemoglobin levels remain greater than 30% or if signs and symptoms persist. NOTE: Methylene blue is available as follows: 50 mg/10 mL (5 mg/mL or 0.5% solution) single-dose ampules and 10 mg/1 mL (1% solution) vials. Additional doses may sometimes be required. Improvement is usually noted shortly after administration if diagnosis is correct. Consider other diagnoses or treatment options if no improvement has been observed after several doses. If intravenous access cannot be established, methylene blue may also be given by intraosseous infusion. Methylene blue should not be given by subcutaneous or intrathecal injection. NEONATES: DOSE: 0.3 to 1 mg/kg.
H) ENHANCED ELIMINATION
1) It is unknown if hemodialysis would remove potassium permanganate. Dialysis should not be routinely recommended.
I) PATIENT DISPOSITION
1) HOME CRITERIA: Patients who are asymptomatic after inadvertent exposure to small amounts and are otherwise improving may be managed at home.
2) OBSERVATION CRITERIA: Patients with a deliberate ingestions, and those who are symptomatic need to be monitored until they are clearly improving and clinically stable.
3) ADMISSION CRITERIA: Patients with severe symptoms should be admitted for treatment and monitoring. Patients with respiratory failure, GI burns, hemodynamic instability, gastrointestinal bleeding, or large ingestions should be admitted to an intensive care setting.
4) CONSULT CRITERIA: Consult a regional poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear. Patients with severe eye irritation/burns should be evaluated by an ophthalmologist. Consult a gastroenterologist to perform endoscopy to evaluate for any GI injury and determine prognosis for guiding further management. Patients with severe or extensive dermal burns should be evaluated by a burn specialist.
J) PITFALLS
1) Failure to detect airway compromise and properly manage airways. Failure to detect/recognize methemoglobinemia, hemolysis, ARDS, pancreatitis, hepatitis, and acute renal injury.
A) DECONTAMINATION: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, the patient should be seen in a healthcare facility.
B) CAUSTIC EYE DECONTAMINATION: Immediately irrigate each affected eye with copious amounts of water or sterile 0.9% saline for about 30 minutes. Irrigating volumes up to 20 L or more have been used to neutralize the pH. After this initial period of irrigation, the corneal pH may be checked with litmus paper and a brief external eye exam performed. Continue direct copious irrigation with sterile 0.9% saline until the conjunctival fornices are free of particulate matter and returned to pH neutrality (pH 7.4). Once irrigation is complete, a full eye exam should be performed with careful attention to the possibility of perforation.
C) EYE ASSESSMENT: The extent of eye injury (degree of corneal opacification and perilimbal whitening) may not be apparent for 48 to 72 hours after the burn.
0.4.5 DERMAL EXPOSURE
A) OVERVIEW
1) DECONTAMINATION: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).
Rumack BH POISINDEX(R) Information System Micromedex, Inc., Englewood, CO, 2017; CCIS Volume 172, edition expires May, 2017. Hall AH & Rumack BH (Eds): TOMES(R) Information System Micromedex, Inc., Englewood, CO, 2017; CCIS Volume 172, edition expires May, 2017.
