What is the management approach for a patient with Harpic (bleach) poisoning?

Management of Harpic (Hydrochloric Acid-Based Toilet Cleaner) Poisoning

Do NOT induce vomiting or perform gastric lavage in Harpic poisoning, as this significantly increases the risk of aspiration pneumonitis and further esophageal injury; instead, focus on immediate airway protection, supportive care, and monitoring for both aerodigestive tract injury and respiratory complications. 1

Immediate Priorities and Stabilization

• Contact poison control immediately for expert toxicological guidance, as specialized consultation facilitates rapid and effective therapy 2, 3, 4
• Assess and secure the airway urgently - patients may develop stridor and require early intubation due to laryngeal edema from acid fumes and aspiration 1
• Implement standard resuscitation measures: ensure adequate oxygenation, ventilation support if needed, and hemodynamic stabilization 5, 6
• Place unconscious patients in the left lateral head-down position and administer glucose if hypoglycemic 5

Critical Contraindications in Acid Poisoning

• Do NOT induce vomiting - this dramatically increases aspiration risk and worsens pulmonary complications from hydrochloric acid 1, 5
• Do NOT perform gastric lavage - carries serious risk of perforation and inducing regurgitation/vomiting 5, 1
• Do NOT blindly insert nasogastric tube - high risk of perforation of damaged esophageal/gastric mucosa and induction of vomiting 1
• Do NOT administer activated charcoal unless specifically advised by poison control, as it is ineffective for caustic injuries and may obscure endoscopic visualization 3, 4

Decontamination

• Remove all contaminated clothing immediately and thoroughly wash exposed skin with copious soap and water to prevent continued absorption 2, 3, 4
• Healthcare providers must use appropriate personal protective equipment to prevent secondary contamination 3, 4

Respiratory Management - High Priority

• Maintain high index of suspicion for chemical pneumonitis - patients who vomit after ingestion or inhale fumes are at significant risk for respiratory tract injury 1
• Monitor closely for signs of airway compromise (stridor, respiratory distress, hypoxia) and protect airway early if any concern 1
• Provide supplemental oxygen and respiratory support as needed 5
• Consider early intubation before airway edema progresses if any signs of upper airway involvement 1

Gastrointestinal Assessment

• Evaluate for esophageal and gastric mucosal injury through careful clinical assessment 1
• Early endoscopy may be indicated to assess extent of caustic injury, but timing should be determined in consultation with gastroenterology and toxicology 1

Symptomatic Management

• Administer benzodiazepines (diazepam or midazolam) for seizures or severe agitation if they occur 7, 2, 3, 4
• Treat extreme agitation with diazepam or clorazepate if no respiratory depression risk; otherwise use haloperidol 5
• Administer atropine for severe bradycardia if present 5

Metabolic and Supportive Care

• Correct metabolic imbalances and coagulopathy as they develop 1
• Address electrolyte derangements promptly 4
• Maintain adequate fluid resuscitation and hemodynamic support 4

Monitoring Requirements

• Observe patients for at least 48-72 hours minimum, even if initially stable, due to risk of delayed respiratory and gastrointestinal complications 3, 4
• Continuous monitoring for development of respiratory distress, perforation, or other delayed effects 1

Controversial/Unproven Therapies

• Steroids have been tried with no promising results for caustic injuries and are not routinely recommended 1
• No specific antidote exists for hydrochloric acid poisoning 4

Psychiatric Evaluation

• Evaluate risk of short-term relapse in self-poisoning cases, even when condition is not immediately life-threatening 5
• Hospital admission should be proposed or imposed until acute suicide risk has subsided 5

Common Pitfalls to Avoid

• Never delay airway protection while waiting for other interventions - respiratory compromise can develop rapidly 1
• Do not focus solely on gastrointestinal injury while missing concurrent chemical pneumonitis 1
• Never delay treatment waiting for confirmation - treat based on exposure history and clinical presentation 2, 3, 4