CASE REPORT
bleach, toxicity
Intravenous Injection of Household Bleach From the Division of Emergency Medicine, University of Texas Southwestern Medical School, Dallas.
David L Morgan, MD, MS, FACEP
Received for publication May 18, 1992. Accepted for publication June 2, 1992.
The widespread use of household bleach (5.25% sodium hypochlorite) as a disinfectant by IV drug users may cause an increase in the number of IV injections of this substance. We report the case of a 31-year-old man who injected less than 1 mL of bleach and then experienced transient left-sided chest pain and vomiting. The patient did not have any serious complications. This report is similar to the only other reported case in the medical literature of an IV injection of a small amount of bleach. Based on these two reports, household bleach appears to be safe when used as a disinfectant by IV drug users, but more studies are needed. [Morgan DL: Intravenous injection of household bleach, Ann Emerg Med November 1992;21:1394-1395.] INTRODUCTION There is an international effort to encourage IV drug users who share syringes and needles to disinfect them with household bleach (5.25% sodium hypochlorite). 1-3 Sodium hypochlorite is inexpensive, readily available , and known to control HIV transmission.4,z However, this use of bleach by IV drug users may lead to its inadvertent or intentional IV injection. The consequences of the IV injection of sodium hypochlorite are not widely reported.
CASE
REPORT
A 31-year-old man injected 0.3 mL of 5.25% sodium hypochlorite (Clorox ®) into a right antecubital vein and then injected approximately the same amount into a left antecubital vein using a 1.0-mL insulin U-100 syringe. He experienced immediate left-sided chest pain and several episodes of vomiting and was taken to the emergency department by ambulance. On arrival, his vital signs were normal except for blood pressure of 162/98 mm Hg. He was alert, awake, and in no apparent distress. He had tenderness in the right lower q u a d r a n t of his abdomen, and his liver edge was 3 to 4 cm below the coastal margin. There was erythema on both antecubital areas. The ECG, urinalysis, serum electrolytes, arterial blood gas, and serum glucose were normal. Urine toxicology screen was negative. The ethanol level was 135 mg/dL. Measured
NOVEMBER1992
21:11 ANNALS 0F EMERGENCY MEDICINE
1394/133
BLEACH
Morgan
serum osmolality was 324 mOsm/kg; calculated osmolality, 288 mOsm/kg; and osmolar gap, 36 mOsm/kg. The patient said that he felt depressed and h a d seen "bleach injection" when watching a movie. This was the patient's first suicide attempt. We applied warm compresses to each antecubital area and observed him for six hours, during which he experienced neither further chest pain nor vomiting. Following psychiatric consultation and treatment with multivitamins, folate, and thiamine, we discharged him after arranging outpatient follow-up. He continued to do well three days later. DISCUSSION
There are an estimated 1.5 million IV drug users in the United States.1 Studies have shown that more than 90% share needles and syringes with others, which is a known risk behavior for HIV infection, z Many advocate the use of household bleach to clean the injection equipment of this group. 1-3 Thus, there p r o b a b l y will be increasing instances of IV injections of this substance. If small amounts of intravenously injected bleach cause no significant problems, then bleach could be promoted as relatively safe as an HIV disinfectant for IV drug users. Household bleach is well known to be relatively nontoxic when ingested in small amounts.6 There are reports of parenteral injection of sodium hypochlorite, but these usually are inadvertent intramucosal injections into soft tissue during dental procedures and produce only local edema and pain. 7,8 There is one r e p o r t of the IV injection of a small amount of bleach. 9 This patient injected 0.3 mL and ingested 60 mL of sodium hypochlorite (5.25%). He h a d normal l a b o r a t o r y values except for the urine toxicology screen, which was positive for benzodiazepine, methamphetamine, and amphetamine. He was treated with ipecac and activated charcoal and did well. The other r e p o r t e d case of the IV injection of bleach involved a much larger amount. 1° A 69-year-old man hospitalized for meningitis in Italy inadvertently received 150 mL of 1% sodium hypochlorite IV over one hour. He experienced mild hypotension and b r a d y c a r d i a that lasted three days and then had permanent lower-limb paralysis. He also had normal l a b o r a t o r y values and no hemolysis. The author did not believe the paralysis was caused b y the sodium hypochlorite but did think that the b r a d y c a r d i a was due to the direct toxic effect on the cardiac tissues and recommended forced diuresis and hydration. A woman with chronic renal failure inadvertently received a large amount of 5.25% sodium hypochlorite (which was used in cleaning the dialysis machine) in her dialysate. 11 Although her blood was in contact with the bleach through the dialysis membrane for less than two minutes, she h a d an immediate cardiac arrest. Fortunately, she was resuscitated successfully. It was believed that the bleach caused massive hemolysis that lead to hyperkalemia and cardiac arrest.
134/1395
Our padent had no serious long-lasting problems caused by the IV injection of this small amount of bleach. He had erythema on both arms, which may have been caused by local wound dressings or extravasation of the bleach. He had an elevated osmolar gap, which was consistent with his ethanol level. The chest pain and vomiting, which Occurred after the injection, resolved spontaneously. The etiology of these symptoms may have been the bleach or another cause such as alcoholic gastritis. SUMMARY
A man suffered no serious complications after the IV injection of a small amount of sodium hypochlorite, which is consistent with the other reported case of the IV injection of a relatively small amount of bleach. Therefore, such patients probably can be treated conservatively and given reassurance that the sodium hypochlorite-related systemic toxicity is limited. IV drug users who continue to share injection equipment should be encouraged to use bleach as an H1V disinfectant. However, there are serious toxic effects when large amounts of bleach are injected. This case suggests the need for further studies of IV sodium hypochlorite injection toxicity. REFERENCES 1. Des Jarlais DC, Hunt DE: AIDS and Intravenous Drug Use. Washington, DC, National Institute of Justice, 1988,report No. NCJ 108620. 2. Hartgers C, Buning EC,van Santen GW, et al: The impact of the needle and syringeexchange programmein Amsterdam on injecting risk behavior.AIDS 1989;3:571-578. 3. Newmeyer JA: Why bleach? Developmentof a strategy to combat HIV contagion among San Francisco intravenous drug users, in Battjes RJ, Pickens RW (eds): Needle Sharing Among Intra venous Drug Abusers." National and International Perspectives, NIBA Research Monograph 80. Washington, DC, National Institute on Drug Abuse, 1989, p 15t-159. 4. Centersfor Disease Control: Recommendationsfor preventingtransmission of infection with human T-lymphotropic virus type III/lymphadenopathy-associatedvirus in the workplace. MMWR 1985;34:685-694. 5. Martin LS, McDougal JS, LoskoskiSL: Disinfection and inactivation of the human T-lymphotropic virus type III/lymphadenopathy-associatedvirus. JlnfectDis 1985;152:400-403. 6. Eilers MA, Garrison TE: General managementprinciples, in Rosen P, Barkin RM (eds): Emergency Medicine Concepts and Clinical Practice, ed 3. St Louis, Mosby-Yearbook Inc, 1992, p 2472-2473. 7, Decker GL, Cohen S, Borer R: The sequelae of accidentally injecting sodium hypochlorite beyondthe root apex. Oral Surg 1974;38:633-638. 8. Becking AG: Complicationsin the use of sodium hypochlorite during endodantic tre atment. Oral Surg Oral Med Oral Pathai 1991;71:346-348. 9. FronerGA, Rutherford GW, Rokeach M: Injection of sodium hypochlorite by intravenous drug users (letter). JAMA 1987;258:325. 10. Marreni M, Menichetti F: Accidental intravenous infusion of sodium hypochlorite (letter). DICP 1991;25:1008. 11. Hay RH:Accidental systemic exposureto sodium hypochlorite (Clorox)during hemodialysis.Am J Hasp Pharm t981;38:1512-1514. Address for reprints: David L Morgan, MD, MS, FACEP Division of EmergencyMedicine University of Texas Southwestern Medical Center at Dallas 5323 Harry Hines Boulevard Dallas, Texas 75235-8579
ANNALS OF EMERGENCYMEDIOINE 21:11 NOVEMBER1992
bleach, toxicity
Intravenous Injection of Household Bleach From the Division of Emergency Medicine, University of Texas Southwestern Medical School, Dallas.
David L Morgan, MD, MS, FACEP
Received for publication May 18, 1992. Accepted for publication June 2, 1992.
The widespread use of household bleach (5.25% sodium hypochlorite) as a disinfectant by IV drug users may cause an increase in the number of IV injections of this substance. We report the case of a 31-year-old man who injected less than 1 mL of bleach and then experienced transient left-sided chest pain and vomiting. The patient did not have any serious complications. This report is similar to the only other reported case in the medical literature of an IV injection of a small amount of bleach. Based on these two reports, household bleach appears to be safe when used as a disinfectant by IV drug users, but more studies are needed. [Morgan DL: Intravenous injection of household bleach, Ann Emerg Med November 1992;21:1394-1395.] INTRODUCTION There is an international effort to encourage IV drug users who share syringes and needles to disinfect them with household bleach (5.25% sodium hypochlorite). 1-3 Sodium hypochlorite is inexpensive, readily available , and known to control HIV transmission.4,z However, this use of bleach by IV drug users may lead to its inadvertent or intentional IV injection. The consequences of the IV injection of sodium hypochlorite are not widely reported.
CASE
REPORT
A 31-year-old man injected 0.3 mL of 5.25% sodium hypochlorite (Clorox ®) into a right antecubital vein and then injected approximately the same amount into a left antecubital vein using a 1.0-mL insulin U-100 syringe. He experienced immediate left-sided chest pain and several episodes of vomiting and was taken to the emergency department by ambulance. On arrival, his vital signs were normal except for blood pressure of 162/98 mm Hg. He was alert, awake, and in no apparent distress. He had tenderness in the right lower q u a d r a n t of his abdomen, and his liver edge was 3 to 4 cm below the coastal margin. There was erythema on both antecubital areas. The ECG, urinalysis, serum electrolytes, arterial blood gas, and serum glucose were normal. Urine toxicology screen was negative. The ethanol level was 135 mg/dL. Measured
NOVEMBER1992
21:11 ANNALS 0F EMERGENCY MEDICINE
1394/133
BLEACH
Morgan
serum osmolality was 324 mOsm/kg; calculated osmolality, 288 mOsm/kg; and osmolar gap, 36 mOsm/kg. The patient said that he felt depressed and h a d seen "bleach injection" when watching a movie. This was the patient's first suicide attempt. We applied warm compresses to each antecubital area and observed him for six hours, during which he experienced neither further chest pain nor vomiting. Following psychiatric consultation and treatment with multivitamins, folate, and thiamine, we discharged him after arranging outpatient follow-up. He continued to do well three days later. DISCUSSION
There are an estimated 1.5 million IV drug users in the United States.1 Studies have shown that more than 90% share needles and syringes with others, which is a known risk behavior for HIV infection, z Many advocate the use of household bleach to clean the injection equipment of this group. 1-3 Thus, there p r o b a b l y will be increasing instances of IV injections of this substance. If small amounts of intravenously injected bleach cause no significant problems, then bleach could be promoted as relatively safe as an HIV disinfectant for IV drug users. Household bleach is well known to be relatively nontoxic when ingested in small amounts.6 There are reports of parenteral injection of sodium hypochlorite, but these usually are inadvertent intramucosal injections into soft tissue during dental procedures and produce only local edema and pain. 7,8 There is one r e p o r t of the IV injection of a small amount of bleach. 9 This patient injected 0.3 mL and ingested 60 mL of sodium hypochlorite (5.25%). He h a d normal l a b o r a t o r y values except for the urine toxicology screen, which was positive for benzodiazepine, methamphetamine, and amphetamine. He was treated with ipecac and activated charcoal and did well. The other r e p o r t e d case of the IV injection of bleach involved a much larger amount. 1° A 69-year-old man hospitalized for meningitis in Italy inadvertently received 150 mL of 1% sodium hypochlorite IV over one hour. He experienced mild hypotension and b r a d y c a r d i a that lasted three days and then had permanent lower-limb paralysis. He also had normal l a b o r a t o r y values and no hemolysis. The author did not believe the paralysis was caused b y the sodium hypochlorite but did think that the b r a d y c a r d i a was due to the direct toxic effect on the cardiac tissues and recommended forced diuresis and hydration. A woman with chronic renal failure inadvertently received a large amount of 5.25% sodium hypochlorite (which was used in cleaning the dialysis machine) in her dialysate. 11 Although her blood was in contact with the bleach through the dialysis membrane for less than two minutes, she h a d an immediate cardiac arrest. Fortunately, she was resuscitated successfully. It was believed that the bleach caused massive hemolysis that lead to hyperkalemia and cardiac arrest.
134/1395
Our padent had no serious long-lasting problems caused by the IV injection of this small amount of bleach. He had erythema on both arms, which may have been caused by local wound dressings or extravasation of the bleach. He had an elevated osmolar gap, which was consistent with his ethanol level. The chest pain and vomiting, which Occurred after the injection, resolved spontaneously. The etiology of these symptoms may have been the bleach or another cause such as alcoholic gastritis. SUMMARY
A man suffered no serious complications after the IV injection of a small amount of sodium hypochlorite, which is consistent with the other reported case of the IV injection of a relatively small amount of bleach. Therefore, such patients probably can be treated conservatively and given reassurance that the sodium hypochlorite-related systemic toxicity is limited. IV drug users who continue to share injection equipment should be encouraged to use bleach as an H1V disinfectant. However, there are serious toxic effects when large amounts of bleach are injected. This case suggests the need for further studies of IV sodium hypochlorite injection toxicity. REFERENCES 1. Des Jarlais DC, Hunt DE: AIDS and Intravenous Drug Use. Washington, DC, National Institute of Justice, 1988,report No. NCJ 108620. 2. Hartgers C, Buning EC,van Santen GW, et al: The impact of the needle and syringeexchange programmein Amsterdam on injecting risk behavior.AIDS 1989;3:571-578. 3. Newmeyer JA: Why bleach? Developmentof a strategy to combat HIV contagion among San Francisco intravenous drug users, in Battjes RJ, Pickens RW (eds): Needle Sharing Among Intra venous Drug Abusers." National and International Perspectives, NIBA Research Monograph 80. Washington, DC, National Institute on Drug Abuse, 1989, p 15t-159. 4. Centersfor Disease Control: Recommendationsfor preventingtransmission of infection with human T-lymphotropic virus type III/lymphadenopathy-associatedvirus in the workplace. MMWR 1985;34:685-694. 5. Martin LS, McDougal JS, LoskoskiSL: Disinfection and inactivation of the human T-lymphotropic virus type III/lymphadenopathy-associatedvirus. JlnfectDis 1985;152:400-403. 6. Eilers MA, Garrison TE: General managementprinciples, in Rosen P, Barkin RM (eds): Emergency Medicine Concepts and Clinical Practice, ed 3. St Louis, Mosby-Yearbook Inc, 1992, p 2472-2473. 7, Decker GL, Cohen S, Borer R: The sequelae of accidentally injecting sodium hypochlorite beyondthe root apex. Oral Surg 1974;38:633-638. 8. Becking AG: Complicationsin the use of sodium hypochlorite during endodantic tre atment. Oral Surg Oral Med Oral Pathai 1991;71:346-348. 9. FronerGA, Rutherford GW, Rokeach M: Injection of sodium hypochlorite by intravenous drug users (letter). JAMA 1987;258:325. 10. Marreni M, Menichetti F: Accidental intravenous infusion of sodium hypochlorite (letter). DICP 1991;25:1008. 11. Hay RH:Accidental systemic exposureto sodium hypochlorite (Clorox)during hemodialysis.Am J Hasp Pharm t981;38:1512-1514. Address for reprints: David L Morgan, MD, MS, FACEP Division of EmergencyMedicine University of Texas Southwestern Medical Center at Dallas 5323 Harry Hines Boulevard Dallas, Texas 75235-8579
ANNALS OF EMERGENCYMEDIOINE 21:11 NOVEMBER1992
