Bleach Toxicity


Article Author:
Thomas Benzoni


Article Editor:
William Gossman



Managing Editors:
Frank Smeeks
Scott Dulebohn
Scott Dulebohn
Erin Hughes
Pritesh Sheth
S Plantz
Steve Bhimji
James Hughes
Richard Ciresi
Tammy Toney-Butler
Phillip Hynes


Updated:
9/8/2018 8:24:17 PM

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. 

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. These are not covered here. For concerns and exposures, see the individual exposure MSDS (Material Safety Data Sheet.)

Etiology

Bleach exposure may occur by numerous mechanisms. Knowing these mechanisms is crucial to treatment decisions.

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.

Bleach exposure causes:

  • 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.

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 (accustomed to low pH) and skin (in contact with the environment).

Indirect reaction: A high index of suspicion must be maintained for secondary exposures from intentional or unintentional admixture 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, 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 juice 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 bottle, 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 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.

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.

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.


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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

Pediatric cutaneous bleach burns., Lang C,Cox M,, Child abuse & neglect, 2013 Jul     [PubMed]
Acute kidney injury due to intravenous bleach injection., Verma A,Vanguri VK,Golla V,Rhyee S,Trainor M,Abramov K,, Journal of medical toxicology : official journal of the American College of Medical Toxicology, 2013 Mar     [PubMed]
Venous thrombosis following intravenous injection of household bleach., Rahmani SH,Ahmadi S,Vahdati SS,Moghaddam HH,, Human & experimental toxicology, 2012 Jun     [PubMed]
Elucidating mechanisms of chlorine toxicity: reaction kinetics, thermodynamics, and physiological implications., Squadrito GL,Postlethwait EM,Matalon S,, American journal of physiology. Lung cellular and molecular physiology, 2010 Sep     [PubMed]
Storage and utilization patterns of cleaning products in the home: toxicity implications., Sawalha AF,, Accident; analysis and prevention, 2007 Nov     [PubMed]
Ingestion of caustic substances: a 15-year experience., Arévalo-Silva C,Eliashar R,Wohlgelernter J,Elidan J,Gross M,, The Laryngoscope, 2006 Aug     [PubMed]
Short-term respiratory effects of cleaning exposures in female domestic cleaners., Medina-Ramón M,Zock JP,Kogevinas M,Sunyer J,Basagaña X,Schwartz J,Burge PS,Moore V,Antó JM,, The European respiratory journal, 2006 Jun     [PubMed]
Contact inactivation of orthopoxviruses by household disinfectants., Butcher W,Ulaeto D,, Journal of applied microbiology, 2005     [PubMed]

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