What is the treatment for bleach ingestion?

Treatment of Bleach Ingestion

Do not induce vomiting, perform gastric lavage, or administer activated charcoal—these interventions are absolutely contraindicated and cause harm. 1, 2

Immediate Assessment and Stabilization

Secure the airway first, as laryngeal edema from vapor inhalation or aspiration can develop rapidly and represents the leading cause of early mortality. 1

• Assess for stridor, hoarseness, drooling, or respiratory distress immediately upon presentation. 1, 2
• Prepare for early endotracheal intubation if any signs of upper airway compromise are present. 1, 2
• Establish IV access and initiate continuous cardiac monitoring, as systemic toxicity can cause electrolyte disturbances including hypocalcemia, hyponatremia, hypokalemia, and metabolic acidosis. 1

Contact Poison Control Center

Call the Poison Control Center immediately to evaluate systemic toxicity of the specific bleach product and receive agent-specific management guidance. 1, 2

• Identify the exact product name, concentration (household 3-6% vs. industrial strength), quantity ingested, and whether ingestion was accidental or intentional. 1, 3
• Intentional ingestions in adults typically cause more severe injury than accidental pediatric exposures and require psychiatric evaluation. 1

Clinical Evaluation

Examine the oropharynx for burns, erythema, or ulceration, but absence of oral lesions does not exclude esophageal or gastric injury. 2, 3

• Assess for symptoms of corrosive esophagitis: chest pain, dysphagia, odynophagia, drooling, or abdominal pain. 2
• Monitor for systemic toxicity: altered mental status, seizures, metabolic acidosis (particularly hypernatremia and hyperchloremia with large ingestions). 2, 4
• Obtain vital signs and assess for signs of perforation: peritonitis, hemodynamic instability, or respiratory compromise. 1

Laboratory and Imaging Evaluation

Obtain complete blood count, comprehensive metabolic panel, arterial blood gas, and lactate level to assess for systemic toxicity and metabolic derangements. 1

• Obtain chest and abdominal radiographs to evaluate for free air indicating perforation. 1
• Consider contrast-enhanced CT of chest and abdomen 3-6 hours post-ingestion as the preferred initial diagnostic tool, which is more accurate than endoscopy for detecting transmural injuries and predicting stricture risk. 2

Endoscopic Assessment

The need for endoscopy depends on clinical presentation and bleach concentration:

• For household bleach (3-6% sodium hypochlorite) ingestions in children: endoscopy is generally unnecessary if asymptomatic, as commercially available household bleaches have very low gastrointestinal toxicity. 5, 6
• For symptomatic patients or concentrated/industrial bleach ingestions: perform upper endoscopy within 12-48 hours to assess injury severity. 1, 2, 3
• Do not advance the endoscope beyond areas of Grade 3 injury to avoid perforation. 1
• Avoid endoscopy between 1-3 weeks post-ingestion due to significantly higher perforation risk during the healing phase. 2

Surgical Consultation and Indications

Obtain immediate surgical consultation if CT shows transmural necrosis, perforation, mediastinitis, or peritonitis. 1, 2

Emergency surgery is indicated for:

• Esophageal or gastric perforation with extensive contamination. 1
• Signs of peritonitis or hemodynamic instability despite resuscitation. 1
• Extensive transmural necrosis, uncontrolled bleeding, mediastinitis, or pleural empyema. 1

Supportive Care

Administer IV fluids for resuscitation and correct metabolic acidosis with sodium bicarbonate if severe. 4

• Do not give water, milk, or any oral intake unless specifically directed by poison control. 1
• Do not administer antacids or neutralization agents—these are contraindicated and provide no benefit while potentially causing exothermic reactions and increased tissue injury. 1
• Place thoracostomy tubes if pneumothorax develops. 4

Disposition

Admit for observation any patient with symptomatic ingestion, intentional ingestion requiring psychiatric evaluation, or evidence of corrosive injury on imaging. 2

• Asymptomatic children with accidental household bleach ingestion can be observed at home with close follow-up if no clinical signs develop. 5, 6
• All patients with concentrated, industrial, or homemade bleach ingestion require hospitalization and endoscopic evaluation regardless of symptoms. 3, 6
• Monitor for delayed complications including stricture formation (typically within 4 months) requiring endoscopic dilation. 2

Psychiatric Evaluation

Mandatory psychiatric evaluation and follow-up are necessary for all patients with intentional ingestion, as these patients have underlying psychiatric disease and high risk of repeat suicide attempts. 1

Critical Pitfalls to Avoid

The most common fatal error is performing gastric lavage or inducing vomiting, which increases perforation risk and causes aspiration. 1, 4, 7

• Never mix bleach with acids or ammonia during decontamination, as this generates toxic chlorine gas. 8
• Do not rely on absence of oral burns to exclude significant esophageal injury—clinical signs are the most important predictor of gastrointestinal lesions regardless of quantity or concentration. 3
• Recognize that even "benign" household bleach can cause fatal outcomes with large volume ingestions, esophageal perforation, and mediastinitis. 4, 7