II. Background

  1. Chlorine Bleach uses
    1. Whitening of clothing (bleaching)
    2. Cleaning and disinfection
      1. Bleach kills most microorganisms (e.g. viruses, Bacteria, fungi, algae)
  2. Chlorine Bleach components
    1. Bleach is a mixture of Sodium hydroxide (strong base), Hydrogen peroxide (oxidizer) and calcium Hypochlorite
    2. Alkaline solution (pH 12.6) prevents Hypochlorite degradation to Chlorine gas
    3. Alternatives to Chlorine bleach: Non-Chlorine Bleach (peroxide based agents)
  3. Concentrations of sodium Hypochlorite (NaOCl)
    1. Household bleach is 3 to 6% (up to 8% for concentrated) sodium Hypochlorite (NaOCl)
    2. Industrial bleach is 12 to 15% sodium Hypochlorite (NaOCl)
      1. Used for water Decontamination, industrial cleaning (e.g. roofs)

III. Mechanism: Exposures

  1. Aerosolized or Aspiration (lung or eye exposures)
  2. Contact (eye or skin exposures)
  3. Ingestion (gastrointestinal)
  4. Toxic gas exposure when bleach is mixed with other agents (esp. other cleansers)
    1. Chlorine gas exposure occurs when bleach is mixed with acid
    2. Chloramine gas exposure occurs when bleach is mixed with ammonia

IV. Findings

  1. Skin
    1. Local irritation in regions of contact
    2. May contaminate mucous membranes (e.g. fingers touch eyes)
  2. Eyes
    1. See Chemical Eye Injury
    2. Chemical Conjunctivitis
    3. Corneal Injury
  3. Gastrointestinal
    1. Mucosal burn
    2. Esophagitis, ulceration, necrosis or Esophageal Perforation
    3. Gastritis, necrosis or gastric perforation
    4. Mediastinitis
  4. Metabolic
    1. Acidosis
    2. Hypernatremia
    3. Hyperchloremia

V. Labs

  1. Serum electrolytes
    1. Indicated in large ingestions

VI. Imaging

VII. Procedures

  1. Endoscopy
    1. Indicated in symptomatic ingestion with pain, Dysphagia, Hematemesis
    2. Indicated in large, typically intentional ingestion (>40 ml or >5 ml/kg)

VIII. Management

  1. See Caustic Ingestion
  2. Decontamination
    1. Avoid Activated Charcoal (contraindicated)
    2. Irrigate eyes if exposed
    3. May rinse mouth, skin if irritated
  3. Children
    1. Most ingestions are small and require evaluation only if symptomatic
    2. Esophageal burns may occur
  4. Adults
    1. Observe for 4-6 hours after ingestion
    2. Manage airway as needed
    3. Consider early endoscopy for larger or symptomatic ingestions
    4. May discharge home when asymptomatic and able to eat and drink

IX. References

  1. Tomaszewski (2020) Crit Dec Emerg Med, COVID-19 Special Edition
  2. Benzoni and Hatcher (2020) Bleach Toxicity, StatPearls, accessed 8/28/2020
    1. https://www.ncbi.nlm.nih.gov/books/NBK441921/

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