Bleach Toxicity


Article Author:
Thomas Benzoni


Article Editor:
Jason Hatcher



Managing Editors:
Frank Smeeks
Scott Dulebohn
Erin Hughes
Pritesh Sheth
Mark Pellegrini
James Hughes
Richard Ciresi
Phillip Hynes


Updated:
11/14/2018 7:21:07 AM

Introduction

Bleach refers to a large class of compounds used to whiten or color-lighten materials. They are frequently used for cleaning and disinfection; bleaches kill or control most types of viruses, bacteria, molds, mildews, and algae. Other, less documented, uses include weed killing and preservation of cut flowers. As such, bleaches are ubiquitous. [1][2]

Bleach is chlorine-based such as calcium hypochlorite (bleaching powder) and non-chlorine (peroxidase-based).

Bleaching action occurs through oxidation or reduction. Chlorine bleaches work through oxidation; they break the chemical bond of the chromophore (a color-producing portion of pigment) rendering it non-reactive with light. Reductions convert double bonds to single bonds, again making them non-reactive to visible light.

An additional interesting and useful property of bleaches relates to their antimicrobial (disinfecting) properties. Winter et al. observed that bleaches disinfect by denaturing (unfolding) bacterial proteins, causing them to clump and become useless. This is the same reaction as cooking an egg; in the same fashion, an egg cannot be uncooked.

Bleach, as subsequently used here, refers to common household bleach sold under such brand names as Clorox et al. Bleach contains 3% to 8 % sodium hypochlorite (NaOCl); sodium hydroxide (NaOH) is added to slow decomposition. There are industrial and concentrated forms of bleach that are used to clean equipment and treat water supplies, which are not covered here. For concerns and exposures, see the individual exposure MSDS (Material Safety Data Sheet.) [3]

Etiology

Bleach exposure may occur by numerous mechanisms. Knowing these mechanisms is crucial to treatment decisions.[4][5]

Additionally, you must be aware of the many uses for bleach and realize that people may combine chemicals to achieve an initially desirable goal (fumigation, foliage control, area cleaning, etc.). These chemical combinations may yield undesirable products of the reaction.

Causes of bleach exposure include:

  • Aerosolized by spray (direct or drift): Pulmonary, ocular, dermatologic (lesser)
  • Immersion (direct or splash): Ocular, dermatologic, gastrointestinal (GI)
  • Ingestion: GI, pulmonary
  • Aspiration: Pulmonary

Epidemiology

Bleach is a common household item used for surface cleaning and disinfection, cleaning clothes, and treating fabric. Household bleach, used according to label directions, including recommended ventilation and protection, is surprisingly non-toxic to humans. This may lead to complacency. Misapplied, especially when mixed with other substances, it can be harmful or even lethal.[6][7][8]

McKenzie et al. reported in a 2010 pediatric study over a 16-year period that just under 270,000 US children (< 5 years of age) were injured by household cleaning products. Bleach was the leading source (37%) and usually by ingestion (63%). A spray bottle was the most common source (40%).

Pathophysiology

Bleach is a corrosive, especially to metal surfaces. Bleach itself is readily diluted with water and can be neutralized on surfaces, including skin, with sodium thiosulfate (if necessary).

Direct reaction: Bleach reacts with biological tissues, causing irritation and cell death by protein denaturation. This reaction is most severe for the more sensitive tissues such as the respiratory system and eyes and less severe for more resistant tissues such as GI tract (which is accustomed to low pH) and skin (which is adapted to be in contact with the environment).

Indirect reaction: A high index of suspicion must be maintained for secondary exposures from intentional or unintentional mixing with other chemicals. These secondary reactions may cause the production of more toxic chemicals, each having its toxicity profile. Chief among these is chlorine gas, which has been used as a chemical warfare agent.

Toxicokinetics

The toxicity of bleach depends on where it is applied. It causes significant eye irritation and irritates the mouth and throat but is fairly benign when ingested.

A dangerous problem with bleach occurs if bleach is mixed with other household cleaners, especially toilet bowl cleaners and ammonia. These mixtures result in the release of chlorine gas, an asphyxiant. When chlorine gas contacts moist tissues, such as eyes or lungs, hydrochloric acid (HCl) results. This acid is a digestive molecule and damages tissue. It will cause damage to the airways, asphyxiation, and can result in death.

History and Physical

  • Eyes: Commonly reddened, irritated, and tearing. Vision may be blurry.
  • Mouth/throat: Irritation is normal to the examiner. Absent other caustic ingestants, the mouth and throat are resistant to damage.
  • Skin: Mild irritation may be evident. Do not let the patient spread the chemicals.
  • Stomach/GI tract: These are rare symptoms. The GI tract is resistant and resilient.
  • Respiratory: Irritation, including bronchospasm, can occur. This does not apply to chlorine gas exposure, a much more severe problem. Exposure to chlorine gas can be fatal.

Evaluation

A routine history and physical exam are sufficient. Be sure to get the container, even if you have to send the family back home for it.

If the bleach was mixed with another chemical, especially toilet bowl cleaners or ammonia, see the section on chlorine gas inhalation.

Treatment / Management

Eyes: At home, flush with tap water. In the Emergency Department, use a topical anesthetic and irrigate with a balanced salt solution. Control pain with a topical anesthetic, such as tetracaine or proparacaine. Place two drops on the medial canthus of the eye then gently pry open the lid. Direct installation is nearly impossible due to blepharospasm. The cornea should be stained with fluorescein and examined under a slit lamp. Look for corneal ulcers or other signs of damage. Corneal abrasions will be common, either from the patient rubbing his eyes or the home treatment to irrigate. Corneal edema may also be evident. A Wood's lamp may substitute for a slot lamp, but significant detail will be lost. Irrigate copiously and be sure to check pH. Advice from an ophthalmologist or emergency physician is in order. [3][5][9]

Skin: At home, wash with gentle soap and water. Treatment is the same in the Emergency Department.

Mouth/throat: In the home and Emergency Department, give plenty of water to drink. Milk may be more soothing but not necessarily.

Stomach/GI tract: At home and in the Emergency Department, do not induce vomiting; if the bleached burned on the way down, it would burn on the way back up. Give plenty of water.

Respiratory:  Use albuterol MDI for signs of bronchospasm; asthmatics may require more aggressive treatment. If exposed to chlorine gas from mixing chemicals, a much more severe course is expected. Bronchoscopy may be required, with lavage as indicated. Admission for observation may be needed as the severity of injury may not be immediately apparent.[2]

Differential Diagnosis

  • Ammonia toxicity
  • ARDS
  • Smoke inhalation injury
  • Hydrogen sulfide inhalation

Pearls and Other Issues

Common household bleach is relatively benign to the skin and GI tract; dilution is usually sufficient.

Eye exposure requires symptomatic treatment; see chemical conjunctivitis.

Respiratory exposure requires symptomatic treatment with special attention to those with reactive airway disease.

The relative lack of toxicity of ingested bleach belies the toxicity of bleach mixed with other household chemicals.

Enhancing Healthcare Team Outcomes

A multidisciplinary approach to bleach toxicity

Bleach toxicity can be serious, and in most cases, it is a preventable injury. While the physicians play a role in the treatment of the injury, the nurse and pharmacist should educate the patient on prevention. The public should be educated on proper labeling and storage of all hazardous chemicals in the home. In addition, the chemicals in the home should not be mixed. When using bleach around the home, one should wear safety goggles, gloves, and long-sleeved garments. Pets and children should be kept away from the treated site for at least 8-12 hours. In addition, when using bleach indoors, adequate ventilation is necessary. The pharmacist should educate the public on symptoms of bleach toxicity and when to seek medical assistance. Finally, patients with lung disease should refrain from using bleach in the home as the fumes may aggravate the disease and lead to acute breathing crisis. [10][8](Level V)

Outcomes

The majority of people exposed to bleach do recover without residual sequelae. However, those with pre-existing lung disease may suffer from lung impairment if the fumes are inhaled. The skin irritation is usually relieved quickly as long as the site is thoroughly irrigated with water. In patients with reactive airway disease, coughing and sloughing of the mucosa may persist for a few days. Long-term follow up reveals that some of these patients may have residual lung and vision impairment for up to 2-3 years after the acute exposure. [6](level V)


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Bleach Toxicity - Questions

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A 5-year-old boy grabbed and drank a cup of lime drink off the counter before his sister could get it. He immediately complained that it tasted bad. The mother explains she had been spot treating stains on the children's clothes and he drank bleach. On exam, except for bleach stains on his blue shirt, the child looks fine. What should be done?



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A patient presents to the emergency department with shortness of breath. She was cleaning the bathroom at home. Through pursed lips, she tells you she had put toilet bowl cleaner in the toilet and could not get out the stains. She added bleach in hope of whitening them. As she worked in the non-ventilated space, her asthma got worse. She has never had such a bad attack. Her vitals are blood pressure 172/105 mmHg, heart rate 124 bpm, respiratory rate 32/min, and SaO2 89% on room air. She does not improve much on an albuterol treatment. What should be done?



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You are in the emergency department when a 30-year-old female with a history of asthma presents with dyspnea. She relates that she was cleaning the bathroom and used bleach to get stains out of the toilet that toilet bowl cleaner did not resolve. Her vitals are T=98.6 F, BP=142/94, R=32, SaO2=89% on room air. What is the best treatment option at this stage?



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You are staffing a well stocked Employee Health station at a food factory. A worker is brought to you with a complaint of eye pain. She was cleaning surfaces with dilute bleach without safety goggles. You consult the Material Safety Data Sheet and find the concentration is 1% hypochlorite (1:5 household). What should be done?



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Bleach can act as a disinfectant as well as changing color. What action of sodium hypochlorite gives it this ability?



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Bleach Toxicity - References

References

Boonekamp C,Voruz F,Fehlmann C, Accidental aspiration of a solid tablet of sodium hydroxide. BMJ case reports. 2018 Jun 21     [PubMed]
Holm SM,Leonard V,Durrani T,Miller MD, Do we know how best to disinfect child care sites in the United States? A review of available disinfectant efficacy data and health risks of the major disinfectant classes. American journal of infection control. 2018 Aug 29     [PubMed]
Kucuk G,Gollu G,Ates U,Cakmak ZA,Kologlu M,Yagmurlu A,Aktug T,Dindar H,Cakmak AM, Evaluation of esophageal injuries secondary to ingestion of unlabeled corrosive substances: pediatric case series. Archivos argentinos de pediatria. 2017 Apr 1     [PubMed]
Kawalilak LT,Fransson BA,Alessio TL, Management of a facial partial thickness chemical burn in a dog caused by bleach. Journal of veterinary emergency and critical care (San Antonio, Tex. : 2001). 2017 Mar     [PubMed]
Rodríguez Vargas BO,Monge Salgado E,Montes Teves P,Salazar Ventura S,Guzmán Calderón E, [Caustics injuries in the upper gastrointestinal tract: clinical and endoscopic features]. Revista de gastroenterologia del Peru : organo oficial de la Sociedad de Gastroenterologia del Peru. 2016 Apr-Jun     [PubMed]
Arif AA,Delclos GL, Association between cleaning-related chemicals and work-related asthma and asthma symptoms among healthcare professionals. Occupational and environmental medicine. 2012 Jan     [PubMed]
Arévalo-Silva C,Eliashar R,Wohlgelernter J,Elidan J,Gross M, Ingestion of caustic substances: a 15-year experience. The Laryngoscope. 2006 Aug     [PubMed]
Mirabelli MC,Zock JP,Plana E,Antó JM,Benke G,Blanc PD,Dahlman-Höglund A,Jarvis DL,Kromhout H,Lillienberg L,Norbäck D,Olivieri M,Radon K,Sunyer J,Torén K,van Sprundel M,Villani S,Kogevinas M, Occupational risk factors for asthma among nurses and related healthcare professionals in an international study. Occupational and environmental medicine. 2007 Jul     [PubMed]
Lang C,Cox M, Pediatric cutaneous bleach burns. Child abuse     [PubMed]
Sawalha AF, Storage and utilization patterns of cleaning products in the home: toxicity implications. Accident; analysis and prevention. 2007 Nov     [PubMed]

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