Bleach can be found in most homes and workplaces across America. This broad, easy availability makes it a candidate for potentially toxic ingestions. When should you assess for structural damage?
A 32-year-old Spanish-speaking male presents to your ED via EMS after coworkers caught him drinking bleach. The incident occurred approximately 45 minutes prior to his arrival in the ED, shortly after he had been reprimanded by his supervisor at the factory where he works. He states he was angry at work but refuses to provide further details or answer additional questions regarding the incident. EMS reports that it was an "industrial bleach" of unknown concentration, and that his coworkers stated that half the contents were missing from the 1-gallon bottle, although they did not know whether it was full prior to ingestion.
The patient admits to a psychiatric history of bipolar disorder and depression. He denies significant nonpsychiatric past medical/surgical history, has no allergies, and took unknown medications in the past for his psychiatric disease but has been noncompliant for years. His vital signs are within normal limits. He is awake, alert, and oriented. Physical exam is unremarkable, revealing clear breath sounds, no signs of caustic injury to oropharynx, and an abdomen that is soft, nontender, and nondistended.
Background
Sodium hypochlorite, commonly known as bleach, is an oxidizing agent that can be found in most homes and workplaces across America, regularly used as a disinfectant and whitening agent.1,2 The use of bleach for these purposes dates back to the early 1800s but became more commonplace in the U.S. in the 1980s.2 Because of its easy accessibility, it is commonly involved in potentially toxic ingestions.
Bleach comes in various concentrations, which carry a difference in potential sequelae. Typical household bleach comes in concentrations ranging from 3-5% and usually does not cause injury beyond local irritation, with minimal gastroenterological effects.1 Large ingestions, or ingestion of higher-concentration bleach (up to 35%), carries a small potential risk for caustic injury.1,3,4 One human study of bleach ingestion done on 393 patients revealed zero cases of perforation, strictures, or long-term sequelae, with the majority of serious adverse outcomes limited to case reports and animal studies.1
Though the risk is low, bleach ingestion has been shown in rare cases to cause severe complications, including strictures, perforation, hypernatremia, hyperchloremic acidosis, and even death. A canine model study showed a single case of perforation following long-term contact.1
For typical household bleach ingestions, most poison centers recommend only conservative home management or supportive care.1,5 We look to provide recommendations for emergency providers as to when it’s important to assess for structural damage after bleach ingestion. This is a task that is always completed by consultants, typically otolaryngology or gastroenterology; though toxicologists and poison centers can also provide recommendations.
Mechanism
Bleach is toxic by direct contact of the hypochlorite moiety of sodium hypochlorite causing damage via liquefactive necrosis.1,4 Saponification of tissue proteins and fats causes cellular damage. Extent of tissue destruction is dependent upon concentration, pH, and degree of exposure.1,4 Because of route of exposure, ingestion of bleach has the potential to cause corrosive or caustic injury to oropharynx, esophagus, or stomach. Symptoms usually present as odynophagia, drooling, stridor, dysphagia, sore throat, vomiting, abdominal pain, or chest pain.1,4 If aspirated, severe respiratory distress and shock can occur due to pulmonary parenchymal damage.1,4
Management
No specific antidote for bleach toxicity or exposure currently exists. In the initial triage, patients should be undressed and decontaminated due to potential risk of secondary exposures. Irrigate any areas potentially exposed with normal saline, D5W, or lactated Ringer’s solution. Airway and breathing should also be immediately evaluated and managed appropriately.1,4 Activated charcoal or anything that can induce emesis is contraindicated, due to risk of aspiration and secondary pulmonary injury. Non-critical patients who have a normal mental status, a patent airway, and the ability to swallow can be provided 4 to 8 ounces of milk or water for dilution of the substance.4
If a bleach ingestion patient presents acutely ill, the patient should immediately be placed on a cardiac monitor and venous access should be obtained. Careful attention should be paid to the ABCs, which must be managed accordingly. If the patient is suffering from a hyperchloremic metabolic acidosis, IV bicarbonate or buffer solutions can be started.4
To Scope or Not to Scope?
Upper endoscopy is a vital tool of prognostic value to determine the extent of injury in a patient suffering from a corrosive ingestion.1-9 Direct visualization of the esophagus via flexible endoscope is the most commonly used method for diagnosis due to the minimal risk of perforation. Endoscopic evaluation is not limited to the esophagus, as there is no correlation between injury to the esophagus and whether the stomach or duodenum are also affected.4 Endoscopy is contraindicated in unstable patients or if there is signs of perforation or airway compromise.4
As emergency providers, we should always assume the worst. If the patient is symptomatic, details are not available regarding the concentration of ingested bleach, or the history is unreliable, then get consultants on board early. Approach symptomatology loosely, as these patients are often unable to provide a reliable history. A study done in the European Journal of Gastroenterology and Hepatology in 2014 reported that clinical signs and symptoms are a poor indicator of severe injury in potential caustic ingestions (sensitivity: 75%), while also recommending early flexible endoscopy in almost all potential cases.9 Though bleach itself is usually not harmful, it is important to keep in mind that there have been cases reported of severe complications, where it would be vital evaluate the extent of injury via endoscopy.1,5,7,9 The timeline of when to initiate this process is highly variable among providers.
Emergency Management Recommendations
While using clinical judgment, contact gastroenterology or otolaryngology early following initial stabilization of the patient, as there is a high level of variability among when flexible endoscopy should be used to look for caustic injury. Literature from toxicology, otolaryngology, and gastroenterology ranges from recommending endoscopy from 4 to 72 hours, with most sources in agreement that patients should be evaluated for endoscopy within 24 hours.1-9 Because of the multi-speciality disaccord, reach out to consultants immediately if corrosive or caustic injury is suspected.
KEY POINTS
● Toxic ingestion patients are often unreliable historians,so approach clinical symptomatology with a grain of salt.
● Key portions of history-taking
- Concentration of product
- Volume of ingestant
- Duration of exposure
- Potential co-ingestants
● Common symptoms
- Odynophagia
- Drooling
- Stridor
- Dysphagia
- Sore throat
- Vomiting
- Abdominal or chest pain
● Management
- ABCs
- Expose and decontaminate
- Can give milk/water if the patient is stable and airway patent
- If critical manage accordingly and keep in mind potential need for bicarbonate infusion
Get consultants on board early! Contact local poison center, consult hospital toxicology team, ENT, or GI.
References
1. Goldfrank L, Hoffman R, Howland MA, Lewan N, Nelson L. Goldfrank’s Toxicologic Emergencies. 10th ed. Columbus, OH: McGraw-Hill Education; 2015.
2. Chisholm H. "Bleaching". Encyclopædia Britannica. 11th ed. Cambridge, UK: Cambridge University Press; 2011.
3. Lupa M, Magne J, Guarisco J, Amedee R. Update on the Diagnosis and Treatment of Caustic Ingestions. Ochsner J. 2009;9(2):54–59.
4. Medical Management Guidelines for Sodium Hypochlorite. Toxic Substances Portal. Agency for Toxic Substances & Disease Registry. 2014.
5. Ros M, Spiller H. Fatal Ingestion of Sodium Hypochlorite Bleach with Associated Hypernatremia and Hyperchloremic Metabolic Acidosis. Vet Hum Toxicol. 1999;41(2):82-6.
6. Pahlavan S. Department of Grand Rounds: Caustic Ingestion. Baylor College of Medicine.
7. Naik R, Vadivelan M. Corrose Poisoning: Review Article. Indian Journal of Clinical Practice. 2012;23(2).
8. Kyung S. Evaluation and Management of Caustic Injuries from Ingestion of Acid or Alkaline Substances. Clin Endosc. 2014;47(4):301–307.
9. Boskovic A, Stankovic I. Predictability of gastroesophageal caustic clinical findings: is endoscopy mandatory in children? Eur J Gastroenterol Hepatol. 2014;26:499–503.