Bleach Poisoning

 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:

1. http://www.atsdr.cdc.gov/MMG/MMG.asp?id=927&tid=84
2. https://medlineplus.gov/ency/article/002488.htm
3. http://emedicine.medscape.com/article/813772-medication#5
4. http://www.inchem.org/documents/pims/chemical/pim495.htm#SectionTitle:10.1 General principles
5. http://www.uptodate.com.
6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096249/
7. Demographic Features of Drug and Chemical Posisoning in Northen Malaysia Retrived from http://www.ncbi.nlm.nih.gov/pubmed/15822759