What is the management approach for a patient who ingested bleach in the emergency department?

Emergency Management of Bleach Ingestion

Immediately irrigate the mouth with copious amounts of water for at least 15 minutes, assess for airway compromise and signs of corrosive injury, contact Poison Control (1-800-222-1222), and do NOT induce vomiting, perform gastric lavage, or administer activated charcoal. 1, 2, 3

Immediate First Aid and Stabilization

• Begin water irrigation immediately without waiting for EMS arrival—irrigate the mouth and any affected skin with large volumes of water for at least 15 minutes 3
• Contact Poison Control Center (1-800-222-1222) while initiating irrigation to obtain product-specific guidance on concentration, expected toxicity, and monitoring needs 1, 2
• Activate EMS immediately if the patient exhibits any life-threatening signs including altered mental status, seizures, respiratory difficulty, drooling, stridor, or hemodynamic instability 1, 2

Airway Assessment and Management

• Assess for airway compromise immediately by checking for stridor, drooling, difficulty swallowing, or respiratory distress, as bleach can cause severe oropharyngeal and laryngeal edema 2
• Prepare for early endotracheal intubation if signs of upper airway edema, respiratory distress, or inability to protect the airway are present 2
• Monitor for aspiration and toxic gas inhalation complications, particularly if the patient has vomited 3

Absolutely Contraindicated Interventions

• Do NOT induce vomiting or administer ipecac—this is absolutely contraindicated as it provides no benefit and can cause aspiration and further corrosive injury 1, 2
• Do NOT perform gastric lavage—this is contraindicated in corrosive ingestions and can cause perforation and worsen esophageal injury 2
• Do NOT administer activated charcoal—it is ineffective for bleach ingestions and may cause aspiration or obstruct endoscopic visualization 1, 2
• Do NOT give milk or water by mouth unless specifically advised by Poison Control, as dilution has not been shown to provide clinical benefit and may induce vomiting 1

Clinical Assessment and Risk Stratification

Household vs. Industrial Bleach

• Household bleach (5.25% sodium hypochlorite) typically causes minimal injury with small accidental ingestions, while industrial or homemade bleaches (>10% concentration) carry significantly higher risk of severe corrosive injury 4, 5
• Children who ingest commercially available household bleaches rarely develop significant mucosal lesions, whereas those ingesting homemade or industrial bleaches are significantly more likely to develop esophagogastric injury 5

Physical Examination

• Examine the oropharynx for burns, erythema, or ulceration, though absence of oral lesions does NOT exclude esophageal or gastric injury 2
• Assess for symptoms of corrosive esophagitis: chest pain, dysphagia, odynophagia, drooling, hematemesis, or abdominal pain 2
• Monitor for signs of perforation: fever, tachycardia, peritoneal signs, pneumomediastinum, or hemodynamic instability 3

Laboratory and Metabolic Assessment

• Check for systemic toxicity: altered mental status, seizures, metabolic acidosis, hypernatremia, and hyperchloremia, particularly with large ingestions 2, 6, 4
• Severe cases can present with hypernatremia (>169 mEq/L), hyperchloremia (>143 mEq/L), and profound metabolic acidosis requiring aggressive correction 6

Diagnostic Imaging and Endoscopy

• Obtain contrast-enhanced CT of chest and abdomen 3-6 hours post-ingestion as the preferred initial diagnostic tool for symptomatic patients or those with significant ingestions—CT is more accurate than endoscopy for detecting transmural injuries and predicting stricture risk 2
• Consider upper endoscopy within 12-48 hours to assess injury severity and guide prognosis, but only after CT evaluation and with experienced practitioners 2
• AVOID endoscopy between 1-3 weeks post-ingestion due to significantly higher perforation risk during the healing phase 2
• Perform systematic emergency endoscopy for concentrated bleach ingestions (>10%) with clinical signs, or large volume ingestions regardless of concentration 7

Supportive Care and Treatment

• Administer IV fluids for resuscitation and correction of metabolic derangements 6
• Correct metabolic acidosis with sodium bicarbonate if severe 6
• Administer diazepam 0.1-0.3 mg/kg IV (maximum 10 mg) if seizures occur 2
• Place thoracostomy tubes if pneumothorax develops 6
• Provide analgesia as needed for pain control 2

Surgical Consultation and Intervention

• Obtain immediate surgical consultation if CT shows transmural necrosis, perforation, mediastinitis, or peritonitis 2, 3
• Emergency surgery is indicated for signs of perforation, full-thickness necrosis of esophagus or stomach, hemodynamic instability, or severe systemic sepsis 3
• Primary repair with adequate drainage is preferred when feasible; esophageal exclusion or resection may be necessary for extensive injury 3

Disposition and Follow-Up

Admission Criteria

• Admit for observation any patient with symptomatic ingestion, intentional ingestion requiring psychiatric evaluation, or evidence of corrosive injury on imaging 2
• Hospitalize all patients who ingested concentrated bleach (>10%) regardless of amount, or large volumes (>100 mL) of household bleach 7

Outpatient Management

• Small accidental ingestions of household bleach (<100 mL, <5.25%) in asymptomatic children can be managed at home with Poison Control guidance and close observation 4, 7, 5
• Digestive endoscopy is generally unnecessary for commercially available household bleach ingestions in children without symptoms 5

Long-Term Monitoring

• Monitor for delayed stricture formation (typically within 4 months) requiring endoscopic dilation in patients with Grade IIb or higher injuries 1, 2
• Psychiatric evaluation is mandatory for all intentional ingestions prior to hospital discharge 1

Common Pitfalls to Avoid

• Do not rely on absence of oral burns to exclude significant esophageal or gastric injury—endoscopy or CT may still be needed based on symptoms and ingestion details 2
• Do not delay imaging or endoscopy in symptomatic patients while waiting for "observation period"—early assessment guides management 2
• Do not underestimate industrial or homemade bleach products—these have significantly higher concentrations and toxicity than household products 5
• Do not perform routine endoscopy on asymptomatic children who ingested small amounts of household bleach—clinical signs are the best predictor of injury 7, 5