What is the treatment for a patient of unknown age and medical history exposed to bleaching powder fumes due to ingestion or handling?

Treatment for Bleaching Powder Ingestion and Fume Exposure

Immediately remove the patient from the exposure source, irrigate affected areas with copious amounts of water for at least 15 minutes, do NOT induce vomiting or give anything by mouth unless directed by poison control, and contact emergency services and poison control center immediately. 1, 2

Immediate Decontamination

For Skin/External Exposure

• Remove all contaminated clothing immediately using gloves to avoid secondary contamination 1
• Irrigate affected skin with large amounts of water for at least 15 minutes - this is the cornerstone of treatment and should not be delayed 1
• Never apply neutralizing agents or use sodium hypochlorite solutions for decontamination 1

For Eye Exposure

• Flush eyes immediately with copious amounts of water for at least 15 minutes (Class I, Level of Evidence B-NR) 1

For Ingestion

• Do NOT induce vomiting - this is absolutely contraindicated and can cause aspiration and further injury 2, 3
• Do NOT perform gastric lavage - contraindicated in corrosive ingestions and can cause perforation 3, 4
• Do NOT administer activated charcoal - not effective for bleach ingestions and may obstruct endoscopy 2, 3
• Do NOT give ipecac syrup - provides no benefit and increases aspiration risk 2, 3
• For household bleach specifically, small amounts of water for dilution may be appropriate, but only if advised by poison control 2

Airway Management Priority

• Assess immediately for signs of airway compromise: stridor, drooling, difficulty swallowing, respiratory distress, or laryngeal edema 3, 5
• Prepare for early endotracheal intubation if upper airway edema, respiratory distress, or inability to protect airway is present 3
• Laryngeal edema may require mechanical ventilation for several days 5

Clinical Assessment

Evaluate for Corrosive Injury

• Examine oropharynx for burns, erythema, or ulceration - though absence of oral lesions does NOT exclude esophageal or gastric injury 3
• Assess for symptoms of corrosive esophagitis: chest pain, dysphagia, odynophagia, drooling, abdominal pain, or hematemesis 3, 4
• Monitor for systemic toxicity: altered mental status, seizures, metabolic acidosis, hypernatremia, hyperchloremia, or hemolysis 6, 4

Laboratory Evaluation

• Obtain serum electrolytes to assess for hypernatremia (can reach 169 mEq/L) and hyperchloremia (can reach 143 mEq/L) 6
• Check arterial blood gas for metabolic acidosis 6, 4

Diagnostic Imaging

The diagnostic approach depends on severity of presentation:

• For symptomatic patients with suspected significant ingestion: Obtain contrast-enhanced CT of chest and abdomen 3-6 hours after ingestion as the preferred initial diagnostic tool - more accurate than endoscopy for detecting transmural injuries and predicting stricture risk 3
• Consider upper endoscopy within 12-48 hours to assess injury severity and guide prognosis, but only after CT evaluation 3, 7
• AVOID endoscopy between 1-3 weeks post-ingestion due to significantly higher perforation risk during the healing phase 3
• Clinical signs are the most important criteria for predicting GI lesions, regardless of quantity or concentration ingested 7

Supportive Care

• Administer antiemetics if nausea is present 2
• Consider proton pump inhibitors or H2-blockers to reduce gastric acid secretion 2, 5
• Treat seizures with benzodiazepines: diazepam 0.1-0.3 mg/kg IV (maximum 10 mg) 3
• Fluid resuscitation for hypotension 6
• Sodium bicarbonate for severe metabolic acidosis 6
• Ensure adequate ventilation in treatment area to prevent inhalation of toxic fumes 2

Disposition Criteria

Admit for Observation If:

• Symptomatic ingestion of any amount 3
• Intentional ingestion requiring psychiatric evaluation 3
• Evidence of corrosive injury on imaging 3
• Large ingestion of concentrated bleach (>5% sodium hypochlorite) 7

Obtain Immediate Surgical Consultation If:

• CT shows transmural necrosis, perforation, mediastinitis, or peritonitis 3, 8
• Esophageal perforation confirmed 8

Home Management May Be Appropriate If:

• Small accidental ingestion of diluted household bleach (<5%) 4, 7
• Asymptomatic patient 4
• Amount less than 100 mL of diluted bleach 7
• Must have poison control center approval 2

Critical Pitfalls to Avoid

• Never delay water irrigation while searching for "better" decontamination solutions 1
• Never mix bleach with other cleaning products, especially ammonia, as this creates toxic gases 2
• Small accidental ingestions are usually benign, but large ingestions or concentrated formulations can cause severe, rarely fatal, corrosive injury 4
• Absence of oral burns does not exclude serious esophageal or gastric injury 3

Long-Term Monitoring

• Monitor for delayed stricture formation (typically within 4 months) requiring endoscopic dilation 3
• Corrosive esophagitis is a risk factor for esophageal cancer in the long-term 5
• Conservative treatment with proton pump inhibitors can improve corrosive esophagitis even with pneumomediastinum 5