How should I manage a patient who has ingested Zonrox bleach (sodium hypochlorite)?

Management of Zonrox (Sodium Hypochlorite) Bleach Ingestion

For household bleach ingestion, provide supportive care without gastrointestinal decontamination, assess for corrosive injury based on clinical symptoms rather than amount ingested, and perform early endoscopy (within 6-24 hours) if any symptoms suggest esophageal or gastric injury are present. 1

Initial Assessment and Risk Stratification

Clinical symptoms are the most reliable predictor of gastrointestinal injury severity, not the volume or concentration ingested. 1, 2

• Assess immediately for signs of corrosive injury: hypersalivation, dysphagia, retrosternal pain, hematemesis, oral mucosal burns, or abdominal pain 1, 3
• The absence of oral lesions or pain does NOT exclude life-threatening gastrointestinal injuries 1
• Contact your regional Poison Control Center to evaluate potential systemic toxicity 1

Key Clinical Distinction

• Household bleach (typically 3-6% sodium hypochlorite): Usually causes mild injuries, though severe complications can occur with large ingestions 1, 3
• Concentrated formulations or massive ingestions: Can cause extensive necrosis requiring emergency surgical intervention 1

Laboratory and Imaging Evaluation

Obtain comprehensive laboratory studies to identify transmural necrosis and guide management 1:

• Complete blood count (leukocytosis predicts transmural necrosis) 1
• Electrolytes: sodium, potassium, chloride, magnesium, calcium (watch for hypernatremia and hyperchloremia) 1, 4
• Arterial blood gas and serum lactate (severe acidosis and elevated lactate indicate transmural necrosis) 1
• Liver function tests (deranged values predict poor outcomes) 1
• Renal function: urea and creatinine (renal failure indicates severe injury) 1
• β-HCG in women of childbearing age 1

Imaging Studies

• Chest and abdominal radiographs: Look for free air indicating perforation 1
• CT chest/abdomen with contrast: Essential for assessing extent of injury, detecting pneumomediastinum, pleural effusion, or pneumothorax 1, 5, 6

Endoscopic Evaluation

Fiberoptic endoscopy is the gold standard for assessing corrosive injury severity and should be performed early in symptomatic patients. 1, 3

• Perform endoscopy within 6-24 hours if ANY clinical symptoms are present (oral burns, dysphagia, chest pain, vomiting, abdominal pain) 1, 2
• Endoscopy assesses injury severity, mortality risk, and likelihood of stricture formation 3
• CT imaging and endoscopy are complementary—both should be utilized in severe cases 3

Important Caveat

• Do NOT perform endoscopy if perforation is suspected on imaging—proceed directly to surgical consultation 1

Management Principles

What NOT to Do

• Do NOT induce vomiting or administer ipecac (increases aspiration risk and worsens injury) 3
• Do NOT perform gastric lavage (contraindicated—can cause perforation) 3
• Do NOT give activated charcoal (ineffective and may obscure endoscopic visualization) 3
• Do NOT administer neutralizing agents (exothermic reactions worsen tissue damage) 1

Supportive Care

Symptom-directed supportive care is the mainstay of treatment as there is no specific antidote. 3

• Airway management: Monitor closely for laryngeal edema; intubate if respiratory compromise develops 6, 3
• Fluid resuscitation: Aggressive IV fluids for hypotension and to correct electrolyte abnormalities 4, 3
• Correct metabolic acidosis: Administer sodium bicarbonate for severe acidosis 4
• Proton pump inhibitor therapy: Initiate to promote mucosal healing 6
• NPO status: Keep patient nil per os until injury severity is determined 1
• Analgesia: Provide adequate pain control 3

Monitoring for Complications

Watch for progression of injury over the first 24-48 hours 1:

• Esophageal perforation: Chest pain, fever, pneumomediastinum on imaging 5, 6
• Gastric perforation: Peritoneal signs, pneumoperitoneum 4
• Systemic toxicity: Progressive hypernatremia, hyperchloremia, worsening acidosis 4, 3
• Respiratory complications: Pneumothorax, pleural effusion requiring chest tube placement 5, 4

Surgical Intervention

Surgical consultation is mandatory for patients with evidence of perforation or transmural necrosis. 1

Indications for surgery include:

• Perforation documented on imaging or endoscopy 1
• Transmural necrosis suggested by severe acidosis, elevated lactate, or extensive CT findings 1
• Extensive mediastinal or peritoneal contamination 1

Surgical options depend on injury extent and patient stability 1:

• Limited contamination with viable tissue: Esophagotomy/gastrotomy with primary repair 1
• Extensive contamination or necrosis: Rescue esophagectomy with delayed reconstruction 1

Disposition

• Asymptomatic patients with small household bleach ingestions: May be observed at home with clear return precautions 2, 3
• Any symptomatic patient: Requires hospital admission for observation and endoscopy 1, 2
• Intentional ingestions: Require psychiatric evaluation before discharge 3

Long-Term Considerations

• Stricture formation risk: Patients with grade 2b or higher corrosive esophagitis require long-term endoscopic surveillance 6
• Esophageal cancer risk: Corrosive injury is a known risk factor; consider esophagectomy in severe strictures depending on patient age and comorbidities 6