Sodium Hypochlorite Poisoning

Aka: Sodium Hypochlorite Poisoning, Chlorine Bleach Ingestion, Bleach Toxicity, Sodium Hypochlorite Toxicity, Disinfectant Poisoning

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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% (over 20% in some cases) 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 (may cause minor, superficial burns)
    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. Oral Mucosal burn, odynophagia, Drooling, Dysphagia or Sore Throat
    2. Esophagitis, ulceration, necrosis or Esophageal Perforation
    3. Gastritis, necrosis or gastric perforation
    4. Mediastinitis
  4. Respiratory
    1. Stridor
  5. Metabolic
    1. Hyperchloremic Metabolic Acidosis
    2. Hypernatremia
    3. Hyperchloremia

V. Labs

  1. Serum Electrolytes
    1. Indicated in large ingestions

VI. Imaging

  1. Chest XRay
    1. Indicated in Inhalation Injury or Dyspnea

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. Nasogastric suction may be considered in massive, recent ingestions
    3. Irrigate eyes if exposed
    4. May rinse mouth, skin if irritated
    5. Remove contaminated clothing
  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. Tomaszewski (2020) Crit Dec Emerg Med 34(2): 28
  3. Benzoni and Hatcher (2020) Bleach Toxicity, StatPearls, accessed 8/28/2020
    1. https://www.ncbi.nlm.nih.gov/books/NBK441921/

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