What is the treatment approach for a patient of unknown age and medical history who has ingested an unknown amount of bleaching powder?

Treatment of Bleaching Powder Ingestion

Immediately stabilize airway, breathing, and circulation, dilute the ingested substance with water or milk within 60 minutes if the patient can safely swallow, and avoid gastric lavage, induced vomiting, or neutralization attempts as these are contraindicated and may worsen injury. 1, 2, 3

Immediate Management

Initial Stabilization and Decontamination

• Contact Poison Control Center immediately to evaluate systemic toxicity and guide management, as bleaching powder ingestion can cause rapid deterioration with metabolic acidosis and multiorgan dysfunction 1, 2
• Assess and secure airway, breathing, and circulation as the first priority 1, 2
• Dilute the corrosive substance with water or milk within 60 minutes of ingestion if the patient is alert and can safely swallow 3
• Remove all contaminated clothing and irrigate any skin or eye exposure with copious amounts of water for at least 15 minutes 2

Critical Contraindications

• Do NOT induce vomiting - this is absolutely contraindicated as it re-exposes the esophagus to the corrosive agent 2, 3
• Do NOT perform gastric lavage - this increases risk of perforation, especially if corrosive injury is suspected 1, 3, 4
• Do NOT attempt neutralization with acids or other agents - this generates heat and worsens tissue damage 2, 3
• Do NOT administer activated charcoal - it has no effect on corrosive substances and is not indicated 3

Diagnostic Evaluation

Laboratory Assessment

• Obtain complete blood count, serum electrolytes (particularly sodium and chloride), liver function tests, arterial blood gases, and renal function tests to assess severity of poisoning 1
• Monitor for hypernatremia, hyperchloremia, and metabolic acidosis, which can occur with significant bleach ingestion 5

Endoscopic Evaluation

• Early endoscopy (within 6-24 hours) is the gold standard for determining presence and severity of corrosive esophageal and gastric lesions 1, 3, 6
• Clinical symptoms alone do not reliably predict the extent of gastrointestinal injury - endoscopy should be guided by presence of clinical signs (oral burns, dysphagia, chest pain, vomiting, abdominal pain) rather than quantity ingested 6
• Avoid endoscopy if perforation is already suspected on imaging 1

Imaging Studies

• Obtain chest X-ray or CT to evaluate for pneumothorax, pneumomediastinum, or pneumoperitoneum, which indicate perforation 4, 5
• Chest CT can reveal air bubbles, abnormal soft tissue density, and pleural effusion suggesting mediastinitis 4

Supportive Care and Monitoring

Fluid and Metabolic Management

• Withhold all oral feedings initially 3
• Carefully assess and correct fluid and electrolyte imbalances 3
• Administer sodium bicarbonate for severe metabolic acidosis - use 50-100 mEq IV bolus for life-threatening acidosis, monitoring arterial pH and serum electrolytes frequently 7, 5
• Ensure adequate ventilation when giving bicarbonate, as it generates CO2 that must be eliminated 7

Monitoring for Complications

• Watch closely for development of esophageal perforation, mediastinitis, pneumothorax, and respiratory distress 4, 5
• Monitor vital signs continuously for hypotension requiring fluid resuscitation 5
• Be alert for delayed complications including stricture formation, which may develop weeks after initial injury 1

Surgical Consultation

• Obtain early surgical consultation if there are signs of perforation (pneumomediastinum, pneumoperitoneum, pleural effusion), extensive necrosis on endoscopy, or clinical deterioration 1
• Up to 1-3% of patients with corrosive ingestions require surgery for complications such as perforation, mediastinitis, or severe bleeding 1
• Delayed esophageal repair and possible colonic transplant may be necessary in severe cases 4

Common Pitfalls to Avoid

• Do not delay water irrigation while searching for "better" decontamination solutions - water is the standard of care 2
• Do not underestimate injury severity based on initial symptoms - the extent of damage may not correlate with presenting signs 1, 6
• Do not delay endoscopic evaluation when clinically indicated, as this misses opportunities for early intervention 1
• Never mix bleach with other cleaning agents during decontamination, as this creates additional toxic chemical reactions 2
• Failing to monitor for delayed complications is a critical error 1

Special Considerations

• Consider psychiatric evaluation for intentional ingestions 1
• Most household bleach ingestions (3-6% sodium hypochlorite) follow a benign course, but concentrated formulations and large volumes can cause severe complications including perforation and death 4, 5, 6
• The concentration and volume ingested, along with clinical signs, should guide intensity of monitoring and intervention 6