What are the immediate treatment steps for a patient, particularly vulnerable populations such as children, the elderly, and those with pre-existing gastrointestinal conditions, who has ingested sodium hypochlorite (NaOCl)?

Immediate Management of Sodium Hypochlorite Ingestion

Do NOT induce vomiting or perform gastric lavage—dilution with water or milk is the only appropriate immediate intervention, followed by urgent assessment for corrosive injury. 1

Immediate First Aid (Within Minutes)

• Dilute immediately with 120-240 mL of water or milk to reduce local corrosive effects 1
• Do NOT induce vomiting as this causes re-exposure of the esophagus to the corrosive agent 1
• Do NOT attempt gastric lavage or activated charcoal—gastrointestinal decontamination is contraindicated and potentially harmful 1
• Remove any contaminated clothing to prevent continued skin exposure 1

Initial Clinical Assessment

Determine Severity Based on Product Concentration and Volume

• Household bleach (3-6% sodium hypochlorite): Small accidental ingestions (<10 mL) rarely cause significant toxicity 1
• Industrial/concentrated solutions (>10%): Even small volumes can cause severe corrosive injury 1
• Large volume ingestions: Any ingestion >100 mL of household bleach warrants aggressive evaluation 1

Key Clinical Features to Assess

• Corrosive injury indicators: Hypersalivation, dysphagia, retrosternal pain, hematemesis, or oral burns indicate severe injury requiring immediate endoscopy 1
• Systemic toxicity signs: Metabolic acidosis, hypernatremia, and hyperchloremia can develop from large ingestions 1
• Airway compromise: Assess for stridor, hoarseness, or respiratory distress from oropharyngeal edema 1

Diagnostic Evaluation

For Symptomatic Patients or Large Ingestions

• Fiberoptic endoscopy should be performed as soon as possible (ideally within 12-24 hours) to assess severity of corrosive injury, predict mortality risk, and evaluate stricture formation risk 1
• CT chest/abdomen is complementary to endoscopy for assessing transmural injury and perforation 1
• Laboratory studies: Obtain arterial blood gas, serum electrolytes (sodium, chloride), and renal function to detect metabolic acidosis, hypernatremia, and hyperchloremia 1

For Asymptomatic Small Ingestions

• Observe for 4-6 hours for development of symptoms 1
• If patient remains completely asymptomatic after household bleach ingestion of <10 mL, discharge with return precautions is appropriate 1

Supportive Management

Symptom-Directed Care (No Specific Antidote Exists)

• Pain control: Provide adequate analgesia for retrosternal or abdominal pain 1
• NPO status: Keep patient nil per os until corrosive injury is ruled out by endoscopy 1
• IV fluids: Administer crystalloids to maintain hydration and correct electrolyte abnormalities 1
• Airway management: Intubate early if signs of airway edema develop, as delayed intubation becomes extremely difficult 1

Monitoring Parameters

• Continuous pulse oximetry and cardiac monitoring for severe cases 1
• Serial electrolytes every 4-6 hours for the first 24 hours in symptomatic patients 1
• Strict intake/output monitoring to assess renal function 2

Special Considerations for Vulnerable Populations

Children

• Lower threshold for toxicity: Children develop symptoms at lower doses due to smaller body mass 1
• Higher aspiration risk: Young children are more likely to cough and aspirate during ingestion, causing additional airway injury 1
• Behavioral factors: Accidental ingestions in children are typically small volumes, but intentional ingestions in adolescents may involve larger amounts 1

Elderly Patients

• Impaired protective reflexes: Reduced gag reflex increases aspiration risk 1
• Baseline renal dysfunction: Pre-existing kidney disease increases susceptibility to sodium hypochlorite-induced nephrotoxicity 2
• Polypharmacy considerations: Concurrent medications may complicate metabolic derangements 2

Patients with Pre-existing GI Conditions

• Increased perforation risk: Those with peptic ulcer disease, inflammatory bowel disease, or prior GI surgery have compromised mucosal integrity 1
• Delayed healing: Underlying GI pathology impairs tissue repair and increases stricture formation risk 1

Critical Pitfalls to Avoid

• Never neutralize with acids or bases—this creates an exothermic reaction causing additional thermal injury 1
• Do not delay endoscopy beyond 24 hours in symptomatic patients, as tissue friability peaks at 5-15 days making later endoscopy dangerous 1
• Avoid empiric corticosteroids—there is no evidence supporting their use and they may mask perforation 1
• Do not rely on absence of oral burns to exclude esophageal injury—up to 30% of patients with significant esophageal injury have no visible oral lesions 1

Disposition Decisions

Admit to Hospital If:

• Any symptoms of corrosive injury (dysphagia, chest pain, vomiting, hematemesis) 1
• Ingestion of >100 mL of household bleach or any amount of concentrated solution 1
• Intentional ingestion regardless of volume 1
• Vulnerable populations (young children, elderly, pre-existing GI disease) with any symptomatic ingestion 1

Safe for Discharge If:

• Completely asymptomatic after 4-6 hour observation 1
• Confirmed small accidental ingestion (<10 mL) of household bleach 1
• Reliable patient/family with clear return precautions 1