CASE FILES – Fireworks Ingestion

Toxicology Case Files from the Utah Poison Control Center

Teaching Points

• Ingestion of fireworks containing barium may result in severe, life-threatening hypokalemia
• Barium creates bright green colors in fireworks
• Fireworks may also contain yellow phosphorus, chlorates, arsenic, as well as other metals and irritants

Case

On the 4^th of July weekend, a 4-year-old male ingested at least one “snake” firework. The family was unsure of the brand and whether it was a domestic or imported product.

The child was monitored in the ED for 4 hours with serial lab measurements of potassium. Fortunately, he remained asymptomatic with normal potassium concentrations and was discharged home.

Barium-containing fireworks ingestion

Fireworks may contain a wide variety of chemical compounds to impart color or other effects. Barium salts impart a bright green color to fireworks.

Ingestion of barium-containing fireworks may lead to severe, life-threatening hypokalemia. Barium salts used in medical settings, such as barium sulfate, are very insoluble, are not absorbed systemically, and do not cause toxicity. The chloride and nitrate salts, however, are very water soluble allowing significant absorption.

The mechanism of barium-induced hypokalemia appears to be via inhibition of K+ efflux channels (Nagel 1979).

A 35-year-old male ingested a combination of 16 “color snakes” and “black snakes.” He was symptomatic with vomiting and hypokalemia of 2.1 mEq/L on presentation about 2 hours after ingestion. He subsequently developed wide-complex tachycardia with a potassium of 1.5 mEq/L. He was treated with a total of 771 mmol of potassium over 6 days. He also developed hypophosphatemia of 0.22 mEq/L. He was hospitalized for 12 days and eventually discharged (Rhyee 2009). Hypokalemia from ingestion of barium-containing sparklers as well as an unknown firework product is also reported (Stanley 2019, Deepthiraju 2012).

Other compounds in fireworks may also cause toxicity: hepatotoxicity resulted from ingestion of yellow phosphorus, and mild arsenic toxicity occurred after ingestion of arsenic-containing snakes (Fernandez 1995, Brayer 1997). These compounds are not allowed in fireworks in the United States, however, non-compliant fireworks could still be imported.

The exact compounds in a particular firework product may not be readily known. Patients will likely develop significant gastrointestinal symptoms from the caustic and irritant effects of any substantial ingestion. Screening for heavy metal exposure could be considered on a case-by-case basis. Fortunately, severe poisoning resulting in hypokalemia is very rare. Of nearly 15,000 fireworks ingestions reported to poison centers, only 7 received treatment with potassium (internal National Poison Data System report).

References

1. Nagel W. Inhibition of potassium conductance by barium in frog skin epithelium. Biochim Biophys Acta. 1979 Apr 4;552(2):346-57. doi: 10.1016/0005-2736(79)90289-x. PMID: 312660.
2. Rhyee SH, Heard K. Acute barium toxicity from ingestion of "snake" fireworks. J Med Toxicol. 2009 Dec;5(4):209-13. doi: 10.1007/BF03178269. PMID: 19876854; PMCID: PMC2845971.

3. Stanley MK, Kelers K, Boller E, Boller M. Acute barium poisoning in a dog after ingestion of handheld fireworks (party sparklers). J Vet Emerg Crit Care (San Antonio). 2019 Mar;29(2):201-207. doi: 10.1111/vec.12820. Epub 2019 Mar 12. PMID: 30861291.

4. Deepthiraju B, Varma PR. Barium toxicity a rare presentation of fireworks ingestion. Indian Pediatrics. 2012 Sep;49(9):762. DOI: 10.1007/s13312-012-0144-z. PMID: 23024089.

5. Fernandez OU, Canizares LL. Acute hepatotoxicity from ingestion of yellow phosphorus-containing fireworks. Journal of Clinical Gastroenterology. 1995 Sep;21(2):139-142. DOI: 10.1097/00004836-199509000-00015. PMID: 8583080.

6. BRAYER, ANNE F. MD; CALLAHAN, CHARLES M. MD, MPH; WAX, PAUL M. MD. Acute arsenic poisoning from ingestion of “snakes”. Pediatric Emergency Care: December 1997 - Volume 13 - Issue 6 - p 394-396