What is the management approach for an adult or child with no significant pre-existing medical conditions after accidental chlorine ingestion?

Management of Accidental Chlorine Ingestion

For accidental chlorine ingestion, immediately irrigate the mouth with copious amounts of water for at least 15 minutes, do NOT induce vomiting or give activated charcoal, and contact Poison Control immediately while assessing for signs of corrosive injury that would require emergency endoscopy and surgical consultation. 1, 2

Immediate First Aid and Decontamination

The cornerstone of treatment is immediate and thorough water irrigation:

• Irrigate the mouth and any affected oral tissues with large amounts of running water for at least 15 minutes to dilute and remove residual chlorine. 1, 2
• If skin contact occurred, immediately remove all contaminated clothing and irrigate affected areas with copious running water for at least 15 minutes. 1
• For eye exposure, begin irrigation immediately with copious water for at least 15 minutes and continue until emergency services arrive, as this is the single most critical intervention. 1, 2
• Use personal protective equipment when providing care to avoid contaminating yourself or others. 1

Critical Contraindications - What NOT to Do

Several interventions are explicitly contraindicated and will cause harm:

• Never induce vomiting with ipecac or any other method, as this increases the risk of re-exposure to the corrosive agent and potential aspiration. 1
• Do NOT administer activated charcoal unless specifically directed by Poison Control, as it provides no benefit for chlorine ingestion and may cause vomiting. 1, 3
• Do NOT give neutralizing agents, antacids, acids, or any other chemical neutralizers, as these are contraindicated and can cause exothermic reactions leading to additional thermal injury. 1
• Do NOT perform gastric lavage if corrosive injury is suspected, as this significantly increases perforation risk. 1
• Avoid administering water or milk by mouth unless specifically directed by Poison Control, due to risk of emesis and aspiration—the exception is the initial mouth irrigation described above. 1, 3

Emergency Assessment and Poison Control Consultation

Immediate systematic assessment is essential:

• Contact Poison Control Center immediately (1-800-222-1222) to evaluate systemic toxicity of the specific chlorine compound and receive agent-specific management guidance. 1, 2
• Identify the specific chlorine product, concentration, quantity ingested, and whether ingestion was accidental or intentional. 1
• Assess airway patency immediately and prepare for early intubation if stridor, hoarseness, drooling, or respiratory distress develop, as airway compromise from laryngeal edema can develop rapidly and is a leading cause of early mortality. 1
• Monitor for respiratory complications including aspiration, airway edema, and toxic gas inhalation if chlorine gas was also inhaled. 2, 4, 5

Clinical Monitoring and Risk Stratification

Watch for signs of severe injury requiring escalation of care:

• Obtain vital signs and establish continuous cardiac monitoring, as systemic toxicity can cause electrolyte disturbances including hypocalcemia, hyponatremia, hypokalemia, and metabolic acidosis. 1
• Monitor closely for signs of perforation: fever, tachycardia, peritoneal signs, chest pain, or pneumomediastinum. 2
• Assess for dysphagia, drooling, vomiting, hematemesis, or severe chest/abdominal pain, which suggest significant esophageal or gastric injury. 1
• For inhalation exposure, presenting symptoms may include cough (64%), dyspnea (31%), nausea, vomiting, and conjunctival hyperemia. 4

Laboratory and Imaging Evaluation

Obtain baseline studies to assess for systemic toxicity:

• Complete blood count, electrolytes, renal function, liver enzymes, arterial blood gas, and lactate level to assess metabolic derangements. 1
• Hypocalcemia may suggest specific corrosive agents like phosphoric or hydrofluoric acid. 1
• Chest and abdominal radiographs to evaluate for free air indicating perforation. 1

Endoscopic Assessment

Endoscopy is crucial for determining extent of injury:

• Perform urgent esophagogastroduodenoscopy within 12-24 hours of ingestion to assess the extent and severity of injury, as clinical symptoms and oral lesions do not correlate reliably with gastrointestinal damage. 1
• Do not advance the endoscope beyond areas of Grade 3 injury to avoid iatrogenic perforation. 1

Surgical Consultation and Indications

Immediate surgical consultation is mandatory in all cases of suspected corrosive ingestion:

• Emergency surgery is indicated for: esophageal or gastric perforation with extensive contamination, signs of peritonitis, hemodynamic instability despite resuscitation, extensive transmural necrosis, uncontrolled bleeding, mediastinitis, pleural empyema, or peritonitis. 1, 2
• Primary repair with adequate drainage is preferred when feasible for limited injuries with viable tissue edges. 2
• Esophagectomy with delayed reconstruction may be necessary for extensive contamination. 1, 2

Supportive Care for Inhalation Component

If chlorine gas inhalation occurred concurrently:

• Most patients respond to humidified oxygen, corticosteroids, and bronchodilators. 4
• Non-symptomatic or slightly exposed patients may only need symptomatic treatment or observation for 6 hours. 4
• Moderately exposed patients require 24-hour observation and treatment. 4
• Severely exposed patients may develop acute respiratory distress syndrome requiring intubation, mechanical ventilation, bronchodilators, intravenous corticosteroids, and standard ARDS management including prone positioning. 5, 6
• Pulmonary edema can develop 6-8 hours after exposure, requiring vigilant monitoring. 6

Special Considerations

Important clinical nuances:

• Pediatric accidental exposures typically cause less severe injury than massive suicidal ingestions in adults. 1
• Mandatory psychiatric evaluation and follow-up are necessary for all intentional ingestions, as these patients have high risk of repeat suicide attempts. 1
• Reactive airway dysfunction syndrome (RADS) can develop in severely exposed patients, manifesting as persistent cough lasting up to 3 months. 6
• Serial pulmonary function testing may show obstructive or mixed defects initially, but typically recovers to normal by 6 months with appropriate management. 6