Bleach,
Clorox & Sodium Hypochloride
- Based on American
Association of Poison Control Centers (AAPCC) data, household bleach is
the most common alkaline substance people are exposed to, accounting for
more than 49,000 exposures per year.
- The most common household
alkali is bleach, a 3%-6% sodium hypochlorite solution with a pH of
approximately.
- Chlorox is liquid chlorine
bleach containing sodium hypochlorite 5%.
- Chlorox Fresh Mint Concentrated contains 3.985% sodium hypochlorite.
Route of
Exposure
- Toxic effects of
hypochloride are primarily due to corrosive properties of the hypochloride
moiety.
- Hypochloride is toxic by
oral, dermal and inhalation routes.
Inhalation
- Hypochloride solution can
deliberate gasses such as chlorine.
- At low
concentration inhalation of gases may cause eye and nasal irritation, sore
throat, and coughing.
- At higher
concentrations can lead to respiratory distress with airway constriction and
accumulation of fluid in the lungs (pulmonary edema).
- Patients may
exhibit immediate onset of rapid breathing, cyanosis, wheezing, rales, or
hemoptysis.
Skin/eye contact
- Direct contact
with hypochlorite solutions, powder, or concentrated vapor causes severe
chemical burns, leading to cell death and ulceration.
- Following acute exposure it may
irritate the skin and cause burning pain, inflammation and blister.
- Contact with low
concentrations of household bleach causes mild and transitory irritation if the
eyes are rinsed.
Ingestion
- Ingestion
of hypochlorite solutions causes vomiting and corrosive injury to
thegastrointestinal tract.
- Household
bleaches (3 to 6% sodium hypochlorite) usually cause esophageal irritation, but
rarely cause strictures or serious injury such as perforation.
- Commercial
bleaches may contain higher concentrations of sodium hypochlorite and are more
likely to cause serious injury.
- Metabolic
acidosis and pulmonary complications may also be seen after ingestion although
relatively rare.
Management
- There is no specific
antidote for hypochloride poisoning.
- Treatment are supportive.
Initial
Management
|
1) Skin/eye contact
- Flush exposed skin and hair with copious amounts of plain water.
- Irrigate exposed or irritated eye with saline, Ringer's
lactate, or D5W for at least 20 minutes.
- Remove contact lenses if it can be done without additional trauma
to the eye.
- If a corrosive material is suspected or if pain or injury is
evident, continue irrigation.
2) Ingestion
- If patient is conscious and able to swallow should be given 4 to
8 ounces of water or milk It is
very unlikely to be of any benefit after more than 30 minutes.
- Dilutants are contraindicated in the presence of shock, upper
airway obstruction, or in the presence of perforation.
|
Specific
Management
|
General
- Patient’s airway and mental status should be immediately assessed
and continually monitored.
- If possible, it is best to avoid inducing paralysis for
intubation because of the risk of anatomical distortion from bleeding
and necrosis. If a difficult airway is anticipated, IV ketamine can be
used to provide enough sedation to obtain a direct look at the airway.
Inhalation
- Administer supplemental oxygen by mask to patients who have respiratory
symptoms.
- Aerosolized bronchodilator may be used to treat patients who have
bronchospasm.
Skin Exposure
- Patients developing dermal hypersensitivity reactions may require
treatment with systemic or topical corticosteroids or antihistamines.
Eye Exposure
- Check the pH of the conjunctiva every 30 minutes for 2 hours
after irrigation is stopped.
- If the pH is not neutral an irrigating contact lens should be
used to apply continuous irrigation for several hours until the pH of
the tissue normalizes.
Ingestion
- Direct visualization of the esophagus/ endoscopy is of
primary importance for determining the extent of injury.
- All patients who are suspected of having significant ingestion,
or those (such as children) for whom there is an unreliable history,
must have early endoscopy within 36 to 48 hours of ingestion.
- Contraindications for endoscopy include: unstable patient,
evidence of perforation, upper airway compromise, or more than 48 hours
after ingestion.
- Endoscopy past 48 hours is discouraged because of progressive
wall weakening and increased risk of perforation.
|
Contraindicated
Procedures
|
- Use of activated charcoal and anti emetics is
contraindicated because vomiting re-exposes the esophagus and the oropharynx
to the caustic agent, further aggravating injury.
-
- Neutralizing agents (weakly acidic or basic
substances) should not be administered because damage is generally
instantaneous. Furthermore, neutralization releases heat that adds thermal
injury to the ongoing chemical destruction of tissue.
-
- Nasogastric intubation to
remove any remaining caustic material is contraindicated because it may
induce retching and vomiting, which can compound injury and possibly lead to
perforation of the weakened esophagus or stomach.
|
Pharmacological
Management
|
- Antibiotics (3rd generation
Cephalosporin)
- Given for patients with Grade 3 (focal necrosis
& extensive necrosis) caustic injury or when there is a high suspicion
for esophageal perforation.
- Proton Pump Inhibitors
- Can be used to prevent stress ulcers of the
stomach.
- Narcotics Analgesic
- Can be reduce the pain
associated with these ingestions.
- Steroids
- Have been a controversial treatment,
some studies found no difference in the incidence of stricture formation with
the use of steroids while some other claimed otherwise.
|
References:
- http://www.atsdr.cdc.gov/MMG/MMG.asp?id=927&tid=84
- https://medlineplus.gov/ency/article/002488.htm
- http://emedicine.medscape.com/article/813772-medication#5
- http://www.inchem.org/documents/pims/chemical/pim495.htm#SectionTitle:10.1
General principles
- http://www.uptodate.com.
- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096249/
- Demographic Features of Drug
and Chemical Posisoning in Northen Malaysia Retrived from
http://www.ncbi.nlm.nih.gov/pubmed/15822759
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