How should I manage a patient who has ingested household bleach (sodium hypochlorite) or has significant skin or eye exposure?

Management of Household Bleach Exposure

For household bleach (sodium hypochlorite) ingestion, do NOT induce vomiting or give anything by mouth—immediately irrigate skin/eye exposures with copious water for at least 15 minutes, and contact Poison Control for all ingestions to determine need for endoscopy based on concentration and symptoms. 1

Immediate First Aid by Exposure Type

Ingestion Management

• Do not give anything by mouth (no water, milk, or activated charcoal) unless specifically directed by Poison Control, as this may induce vomiting and worsen injury 1, 2
• Never induce vomiting or administer ipecac—this is contraindicated and increases aspiration risk without clinical benefit 1, 3
• Call Poison Control immediately to provide product concentration, volume ingested, and time of exposure 1
• Activate EMS if the patient exhibits: altered mental status, respiratory distress, persistent vomiting, chest pain, or oral mucosal burns 1, 2

Skin Exposure Management

• Remove all contaminated clothing immediately using gloves to avoid self-contamination 1
• Irrigate affected skin with copious amounts of water for at least 15 minutes—this is the cornerstone of treatment (Class I, Level of Evidence B) 1
• Do not apply neutralizing agents—water irrigation is the standard of care 1

Eye Exposure Management

• Flush eyes immediately with large amounts of water for at least 15 minutes (Class I, Level of Evidence C) 1
• Continue irrigation even during transport to medical facility 1

Clinical Assessment and Risk Stratification

Concentration Matters Critically

• Household bleach (3-6% sodium hypochlorite): Generally causes minimal injury, with most children showing no significant esophagogastric lesions on endoscopy 4
• Industrial or homemade bleach (>6% concentration): Significantly more likely to cause severe esophageal perforation, mediastinitis, and systemic toxicity 5, 4

High-Risk Features Requiring Immediate Hospital Evaluation

• Oral mucosal burns, tongue discoloration, or throat pain 6, 7
• Persistent vomiting, chest pain, or dysphagia 5
• Respiratory symptoms: cough, dyspnea, stridor 8
• Altered mental status or slurred speech 6
• Known ingestion of industrial-strength or homemade bleach 4

Hospital Management

Laboratory Monitoring

• Check serum sodium and chloride levels—bleach ingestion can cause life-threatening hypernatremia (>169 mEq/L) and hyperchloremic metabolic acidosis 6
• Arterial blood gas to assess for metabolic acidosis 6
• Monitor for acute kidney injury from oxidative stress 8

Endoscopic Evaluation

• Perform urgent upper endoscopy within 12-24 hours if: industrial/homemade bleach ingestion, symptomatic patients with oral burns, persistent vomiting, chest pain, or dysphagia 5, 4
• Endoscopy is generally unnecessary for asymptomatic children who ingested small amounts of household bleach (<6% concentration) 4
• Avoid endoscopy if perforation is suspected—obtain CT chest/abdomen first to assess for pneumomediastinum, pneumothorax, or free air 5

Imaging

• Obtain chest CT and barium esophagography if esophageal perforation is suspected (chest pain, fever, subcutaneous emphysema) 5
• Look for pneumomediastinum, pleural effusion, or contrast extravasation 5

Supportive Care

• Airway management: Prepare for difficult intubation if oropharyngeal edema present; consider video laryngoscopy 7
• Fluid resuscitation for hypotension and correction of electrolyte abnormalities with isotonic fluids 6
• Sodium bicarbonate for severe metabolic acidosis 6
• NPO status until esophageal injury is ruled out 7

Critical Pitfalls to Avoid

• Never delay water irrigation while searching for "better" decontamination solutions 1
• Do not use sodium hypochlorite solutions to decontaminate other chemical exposures (creates dangerous reactions) 1
• Do not perform gastric lavage—this increases perforation risk and aspiration 2
• Do not assume household bleach is benign—rare cases cause esophageal perforation, mediastinitis, and death even with 4.5-5.25% concentrations 6, 5

Prognosis and Long-Term Complications

• Most household bleach ingestions follow a benign course with conservative management 4, 8
• Severe complications include esophageal stricture, perforation requiring colonic transplant, and death from multi-organ failure 6, 5
• Elderly patients have poor physiological reserve and higher mortality risk 7
• Long-term sequelae include dysphagia requiring gastrostomy, frailty, and significant psychological burden 7