What is the management approach for bleaching powder (sodium hypochlorite) poisoning?

Management of Bleaching Powder (Sodium Hypochlorite) Poisoning

The cornerstone of bleaching powder poisoning management is immediate decontamination with copious water irrigation for at least 15 minutes, removal of all contaminated clothing, and supportive care based on the route of exposure—with most household bleach ingestions following a benign clinical course requiring only observation. 1

Immediate First Aid and Decontamination

Skin Exposure

• Remove all contaminated clothing, shoes, and jewelry immediately to prevent trapped chemicals from causing further injury 1, 2
• Irrigate affected skin with copious amounts of running water for at least 15 minutes 1, 2
• Use gloves or cloth to remove any chemical powder before irrigation to avoid spreading contamination 1
• Never apply neutralizing agents—water irrigation is the standard of care 1

Eye Exposure

• Flush eyes immediately with large amounts of water for at least 15 minutes (Class I, Level of Evidence C) 1
• Continue irrigation even during transport to medical facilities 1

Inhalation Exposure

• Immediately remove the patient from the exposure source and ensure fresh air 2
• Administer 100% oxygen via high-flow mask or endotracheal tube without delay for any respiratory symptoms 2
• Continue oxygen therapy for 6-12 hours until symptoms resolve 2
• Activate emergency medical services immediately if difficulty breathing, shortness of breath, or respiratory distress are present 2

Ingestion

For household bleach ingestion in children, the clinical course is typically benign and most cases do not require hospitalization, endoscopy, or aggressive intervention unless severe symptoms are present. 3, 4

Risk Stratification by Concentration and Volume:

Diluted bleach (<5% sodium hypochlorite):

• If volume <100 mL: Observation at home is appropriate with no hospitalization needed 5
• If volume >100 mL: Consider hospitalization based on clinical symptoms 5

Concentrated bleach (>5% sodium hypochlorite) or tablets:

• Most centers recommend hospitalization regardless of amount 5
• Perform upper GI endoscopy between 6-8 hours post-ingestion if clinical signs of injury are present 5
• For large ingestions, systematic emergency endoscopy may be warranted 5

Key Clinical Decision Points:

• Do not give anything by mouth unless advised by poison center or emergency medical personnel (Class III, Level of Evidence C) 1
• Do not induce vomiting or perform gastric lavage—this can worsen esophageal injury 6
• Clinical signs are the most important predictor of GI lesions, regardless of quantity or concentration ingested 5

Clinical Assessment

Warning Signs Requiring Immediate Medical Evaluation:

• Severe dysphagia or inability to swallow 3
• Persistent vomiting 6
• Chest pain or fever (suggesting perforation or mediastinitis) 6
• Stridor or hoarseness (indicating upper airway involvement) 2
• Facial burns or singed nasal hairs suggesting inhalation injury 2

Diagnostic Workup for Symptomatic Patients:

• Fiberoptic examination of pharynx and larynx should be included in assessment 3
• Upper GI endoscopy is indicated for patients with severe symptoms or signs of significant injury 5, 3
• Chest CT if perforation or mediastinitis is suspected 6
• Pulmonary function testing and blood gas analysis for inhalation exposures 7

Supportive Care

Respiratory Support:

• For inhalation injury with respiratory failure, provide mechanical ventilation with 100% FiO2 2
• Corticosteroids may provide significant alleviation of respiratory complaints and improved lung function in inhalation injuries 7

Monitoring:

• Most accidental household bleach exposures result in minor, transient adverse effects with no permanent sequelae 4
• Hospitalized patients require monitoring for delayed complications such as esophageal stenosis or perforation, though these are rare 6

Critical Pitfalls to Avoid

• Never mix bleach with acids or other cleaning products during cleanup—this generates toxic chlorine gas 4
• Never use sodium hypochlorite solutions to decontaminate acid burns—this creates additional dangerous chemical reactions 1
• Do not delay water irrigation while searching for "better" decontamination solutions 1
• Do not routinely prescribe corticosteroids or antibiotics for simple ingestions without evidence of significant injury 3

Contact Poison Control

Regional poison centers should be contacted for expert advice on management 1, providing information about the character, time, and product name of the poisoning 1