Systemic Barium Toxicity Manifesting As Acute Hypokalemic Paralysis and Respiratory Failure Following a Firework Injury

We present the case of a 63-year-old male who sustained a penetrating soft tissue injury to the right thigh from a commercial firework. Following uncomplicated surgical debridement and discharge, the patient returned within hours exhibiting rapidly progressive ascending paralysis, bulbar weakness, and respiratory failure requiring intubation. Laboratory evaluation revealed profound hypokalemia (1.4 mmol/L), hypophosphatemia, and rhabdomyolysis. The clinical presentation, coupled with the patient’s report of the firework emitting a green flare, is most consistent with acute barium toxicity. Formal toxicologic confirmation was not available; however, the clinical constellation, mechanism of injury, and rapid response to electrolyte repletion strongly support this diagnosis. Barium salts, commonly used in pyrotechnics to produce green coloration, can induce systemic toxicity by competitively blocking potassium channels, causing a widespread intracellular shift of potassium. This case highlights the rare but life-threatening systemic toxicity associated with soluble barium salts and the importance of considering toxicologic etiologies in trauma patients presenting with unexplained neurological collapse.