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

2. 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

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

4. 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

5. 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

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

8. 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

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

10. 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

11. 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

12. 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.

13. 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

14. 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

15. 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

16. 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

17. Thank you