Case of Dettol and Bleach poisoning Dr. Wong Oi Fung AED of TMH

History Mr. Chow; 32/M Good past health; NKDA Brought to AED of TMH at 08:06 on 5/4/2004 Drank ~ 1 liter of Dettol solution mixed with bleach solution in a suicidal attempt Also taken 2 tablets of pain-killer Drank large amount of water before arrival Vomiting several times with clear fluid

Vital signs BP 133/89 Pulse 83 bpm Temp. 36C SpO2 93% on O2 GCS 15/15 Category 2

Physical examination Alert and conscious No stridor Edematous change over soft palate Surgical emphysema over neck Crepitation over bilateral chest Abdomen soft No focal neurological signs Superficial cut wound over left wrist; no tendon injury

Investigation Spot blood glucose 6.1 istat: pH 7.32, HCO3 16.7 ECG SR no ST change CXR showed generalized hazziness over bilateral chest; mediastinal gas X-ray of lateral neck showed no obvious soft tissue swelling; retropharyngeal gas

Progress ICU consulted Prophylactic antibiotic ( augmentin and flagyl ) Poor prognosis explained to relative Admit to ICU ward

Progress on supportive treatment Developed acute renal failure on hemodialysis support pneumomediastinum and surgical emphysema gradually resolved Barium meal esophageal ulcer with no leakage Pyschiatrist consulted paranoid schizophrenia; started haloperidol

Progress Renal function gradually improved Creatinine up to 1300 mmol/L ~ 1 week after admission Cr ~100 mmol/L ~6 week

Progress Readmitted on 1/6/2004 for increasing dysphagia x few days Not tolerate solid or liquid OGD  corrosive esophageal stricture at 26 cm from incisor Readmitted on 8/6/2004 for OGD and dilatation FU surgical unit

Dettol posioning Dettol Widely used as an antiseptic and disinfectant Mixture of 4.8% chloroxylenol, pine oil and isopropyl alcohol Toxicity: Respiratory: largngeal obstruction, upper airway edema (may be delay) and aspiration pneumonia Neurology: CNS depression GI: nausea, vomiting and abdominal pain Renal: acute renal failure

Dettol poisoning Treatment Supportive Maintain airway patency and prevent aspiration Dilution is controversial increased risk of vomiting and aspiration esp. in patient with altered level of consciousness.

Bleach poisoning Household bleach ~5% sodium hypochlorite Alkaline pH 10.0 to 12.0 Exposure: ingestion, inhalation, dermal or eye Toxicity: GI: corrosive damage to upper GI tract( >5ml/Kg) Respiratory: edema of glottis, pulmonary edema and pneumonitis Metabolic: metabolic acidosis, hypernatremia and hyperchloremia Skin: dermal irritation and hypersensitivity Eye: Corneal injury

Bleach Poisoning pneumonitis Mechanism of toxicity for GI tract 2NaCLO + H2O +CO2  Na2CO3 + 2HCLO 2HCLO 2HCL + O2 corrosive injury Inhalation injury Mixed with other acidic toilet bowl cleaners or ammonia NaCLO +HCL + H2O CL2 +2 NaOH NACLO + NH3 NH2CL + Na + OH pneumonitis

Bleach poisoning Treatment: ABC induced emesis, gastric lavage NOT indicated decontamination of skin and eye ? Dilution with water and milk ( 120 to 240 ml) Oxygen +/- ventilatory support Bronchodilator for bronchospasm Steroid for acute lung injury controversial Endoscopy if symptoms (drooling, dysphagia or pain ) are present or large amount (> 5mg/kg) is ingested

Treatment (continued) Surgical emphysema from esophagus or airway? Or both? No early or urgent OGD in this case due to ? poor respiratory status Ba swallow several days post ingestion Cautious early OGD + bronchoscopy preferable? + ET intubation beforehand OGD findings guide any steroid & surgical therapy

Thank you