What is the treatment for a patient with suspected ingestion of bleaching powder?

Treatment of Bleaching Powder Ingestion

Immediately irrigate the mouth and affected areas with copious amounts of water, do NOT induce vomiting or attempt neutralization, and assess for signs of severe injury that would require emergency endoscopy and surgical consultation. 1

Immediate First Aid and Stabilization

Initial Decontamination

• Remove all contaminated clothing immediately to prevent continued exposure and avoid self-contamination 1
• Irrigate the mouth and any affected skin with large amounts of water for at least 15 minutes - this is the cornerstone of treatment 1
• If eyes are exposed, flush immediately with copious water for at least 15 minutes and continue until emergency services arrive 1, 2
• Call emergency medical services while initiating water irrigation - do not delay irrigation while waiting for help 1

Critical "Do Not" Actions

• Do NOT induce vomiting - this is contraindicated as it causes re-exposure of the esophagus to the caustic agent 3, 4
• Do NOT attempt to neutralize the bleach with acids or other substances - this creates additional chemical reactions and heat 1, 3
• Do NOT perform gastric lavage - this is contraindicated in caustic ingestions 3
• Do NOT give activated charcoal - it has no effect on caustic substances 3
• Do NOT give anything by mouth unless specifically advised by poison control 1

Dilution Considerations

• Water or milk dilution may be considered within the first 60 minutes if the patient can swallow safely and has no signs of perforation 3
• However, there is insufficient evidence to strongly support routine dilution as first-aid, and it should not delay emergency care 1

Clinical Assessment and Risk Stratification

Essential Information to Obtain

• Concentration of the bleach product (household dilute ~3-6% vs. concentrated ~12% sodium hypochlorite) 5, 6
• Quantity ingested (small sip vs. large volume) 5
• Time since ingestion 3
• Presence of clinical symptoms - this is the most important predictor of injury severity regardless of concentration or amount 5

Clinical Signs Indicating Severe Injury

• Dysphagia or odynophagia (difficulty or painful swallowing) 4
• Drooling or inability to handle secretions 4
• Stridor or respiratory distress 4
• Severe abdominal pain 3
• Vomiting, especially with blood 3
• Oropharyngeal burns (though absence does not exclude esophageal injury) 6

Important Clinical Pitfall

The absence of oropharyngeal burns does NOT exclude significant esophageal or gastric injury - endoscopy should be performed based on symptoms and exposure characteristics, not just visible oral lesions 6

Hospital Management Algorithm

For Dilute Household Bleach (<6% sodium hypochlorite)

• If quantity <100 mL and patient is asymptomatic: Observation at home may be appropriate with close poison control follow-up 5
• If quantity >100 mL or any symptoms present: Hospital admission and consideration for endoscopy 5

For Concentrated Bleach (>6% sodium hypochlorite) or Bleach Tablets

• Hospitalization is recommended regardless of amount ingested 5
• Emergency upper GI endoscopy within 6-8 hours if clinical signs are present 5
• Some experts recommend systematic emergency endoscopy for large ingestions of concentrated bleach even without symptoms 5

Endoscopic Evaluation

• Esophagogastroscopy is the gold standard for determining presence and severity of caustic lesions 3, 6
• Timing: Perform within 6-24 hours of ingestion when clinically indicated 5
• Grading system: Lesions are classified as Grade 1 (superficial), Grade 2 (transmural injury), or Grade 3 (full-thickness necrosis) 6
• Even asymptomatic children may benefit from endoscopy after concentrated bleach ingestion, as some develop strictures 6

Supportive Care

General Measures

• Maintain NPO status (nothing by mouth) until injury severity is determined 3
• Assess and correct fluid and electrolyte imbalances carefully 3, 7
• Monitor vital signs closely for signs of perforation or systemic toxicity 3
• Provide adequate analgesia for pain control 3

Monitoring for Complications

• Watch for signs of perforation: fever, tachycardia, peritoneal signs, pneumomediastinum 8
• Monitor for respiratory complications: aspiration, airway edema, toxic gas inhalation if mixed with other chemicals 1, 9
• Assess for metabolic acidosis and electrolyte abnormalities in severe cases 7

Surgical Consultation

Indications for Emergency Surgery

• Signs of perforation (free air, peritonitis) 8
• Full-thickness necrosis of esophagus or stomach on endoscopy 8
• Hemodynamic instability despite resuscitation 8
• Severe systemic sepsis 8

Surgical Options

• Primary repair with adequate drainage is preferred when feasible 8
• Esophageal exclusion or resection may be necessary for extensive injury 8
• Damage control approach for unstable patients with abbreviated source control followed by ICU resuscitation 8

Long-Term Complications and Follow-Up

Stricture Formation

• Esophageal strictures develop in approximately 5-10% of cases, particularly after concentrated bleach ingestion 6
• Strictures typically manifest weeks to months after injury 6
• Treatment options include endoscopic dilation for limited strictures or esophageal replacement (colonoplasty) for severe cases 6

Follow-Up Protocol

• All patients with documented esophageal injury require long-term follow-up to monitor for stricture development 6
• Repeat endoscopy may be needed if dysphagia develops 6

Special Considerations for Pediatric Patients

Epidemiology

• Bleach is the most common caustic substance ingested by children (up to 89% of caustic ingestions) 6
• Mean age is approximately 24 months 4
• Most children obtain bleach from open containers like cups rather than original bottles 4

Pediatric-Specific Management

• Most accidental household bleach ingestions in children follow a benign course and do not require hospitalization if dilute product and small amount 4
• Fiberoptic examination of pharynx and larynx should be included in assessment 4
• Corticosteroids and antibiotics are NOT routinely indicated unless severe injury is documented 4
• For eye exposure in children, parental involvement helps facilitate cooperation with irrigation and examination 2

Contact Poison Control

Regional poison centers should be contacted immediately for expert guidance on management, as they can provide specific recommendations based on the exact product, concentration, and clinical scenario 1