Episode #1- Cleaning with War Gas and Drinking Javel Water (Chlorine Gas and Bleach)

The Poison Lab

Ryan and Toxo talk about the the history of a commonly used disinfectant. They break down the many ways it can cause harm if not used appropriately, including creating chemical weapons and turning you...

• Key points
  • Bleach mixed with various chemicals can make many toxic substances
    • Bleach + acid= chlorine gas
      • Bartholette original Cl2 + H2O ⇄ HCl + HClO
      • To drive the reaction to the right, a base was added, to neutralize HCl and reduce the amount of product
      • The reaction is reversed when an acid is added
      • http://www.chm.bris.ac.uk/motm/bleach/Sodium%20Hypochlorite%20-%20Molecule%20of%20the%20Month%20October%202011.pdf
    • Bleach + ammonia= chloramine gas
    • Bleach + rubbing alcohol (isopropyl)= chloroform
    • Bleach + soap= carbon tetrachloride
  • Chlorine gas is a high solubility irritant, it dissolves quickly in the mucous membranes and causes severe irritation of upper airway, eyes and nose (moist mucous membranes), effects are noticed quickly
    • Treatment for most chemical inhalation injuries involves removal from ongoing exposure, maintenance of a patent airway, and supportive care
      • Oxygen for hypoxemia
      • Bronchodilators (albuterol)
      • Intubation if needed
    • If the exposure is to chlorine gas there may be a role for nebulized sodium bicarbonate.
    • Due to initial irritation, exposure may present looking vary severe, but may turn around with good supportive care
  • If you accidentally make chlorine gas, get to fresh air, open windows if you can and call your local poison center or 911
  • Bleach ingestion are basic and can cause a liquefactive necrosis
    • Some may result in oral irritation
    • Treatment involves assessing the injury to determine risk of stricture and possible esophageal stenting
• Brief summary of steroid use with irritant gases: Reproduced with permission from : Pape KO, Feldman R. Smoke inhalation and Toxic Exposure. Chapter In: Erstad B, ed. Critical Care Pharmacotherapy. Lenexa: American College of Clinical Pharmacy. January 2020.
  • Steroid use in pulmonary irritant induced pneumonitis is not well evaluated in randomized controlled trials. Reviews of animal data suggest no significant benefit for poorly water soluble or high doses of water-soluble irritants. They may also have a negative effect on the recovery phase (deLange 2011).Numerous case reports exist detailing positive outcomes from use of steroids in patients exposed to pulmonary irritants (deLange 2011).However, without an appropriate comparator it is not known if symptom resolution is related to the intervention or the natural progression of the disease. Small human crossover trials evaluating the effects of mild ozone exposure found a reduction in bronchiolar lavage inflammatory markers with inhaled fluticasone or budesonide but no difference in clinical effects (deLange 2011, Nightingale 2000, Alexis 2008, Vagaggini 2001). Due to the absence of well controlled trials, steroids are not routinely recommended for chemical pneumonitis. However, there is also a lack of negative data and institutional protocols or patient specific factors may govern their use.
    • 1. De Lange DW, Meulenbelt J. Do corticosteroids have a role in preventing or reducing acute toxic lung injury caused by inhalation of chemical agents? Clin Toxicol (Phila) 2011;49:61-71.
      2. Vagaggini B, Taccola M, Conti I, et al. Budesonide reduces neutrophilic but not functional airway response to ozone in mild asthmatics. Am J Respir Crit Care Med 2001;164:2172–6.
      3. Alexis NE, Lay JC, Haczku A, et a. Fluticasone propionate protects against ozone-induced airway inflammation and modified immune cell activation markers in healthy volunteers. Environ Health Perspect 2008;116:799–805.
      4. Nightingale JA, Rogers DF, Chung KF, et al. No effect of inhaled budesonide on the response to inhaled ozone in normal subjects. Am J Respir Crit Care Med 2000;61:479–86.
• New story from initial case- https://www.msdsonline.com/2015/02/27/fatal-accident-in-ca-even-small-quantities-of-chlorine-pose-danger/
• History
  • Claude Bertholtte- https://www.britannica.com/biography/Claude-Louis-Berthollet
  • Antoine Labarraque- https://peoplepill.com/people/antoine-germain-labarraque/
• Data on sodium bicarbonate in CL2 gas
  • Systematic review
    • Huynh Tuong A, Despréaux T, Loeb T, Salomon J, Mégarbane B, Descatha A. Emergency management of chlorine gas exposure - a systematic review. Clin Toxicol (Phila). 2019;57(2):77‐98. doi:10.1080/15563650.2018.1519193
  • Summary of many trials
    • https://chemm.nlm.nih.gov/countermeasure_sodium-bicarbonate.htm
• Sodium bicarbonate probably doesn’t help Chloramine gas exposure
  • Pascuzzi TA, Storrow AB. Mass casualties from acute inhalation of chloramine gas. Mil Med. 1998;163(2):102‐104.
• Chloramine physical properties
  • https://pubchem.ncbi.nlm.nih.gov/compound/Chloramine
• Reactions of Sodium Hypochlorite wit other compounds to make nasty products -
  • Odabasi M. Halogenated volatile organic compounds from the use of chlorine-bleach-containing household products. Environ Sci Technol. 2008;42(5):1445‐1451. doi:10.1021/es702355u
• Good review of the basics of caustic ingestions such as bleach
  • Hoffman RS, Burns MM, Gosselin S. Ingestion of Caustic Substances. N Engl J Med. 2020;382(18):1739‐1748. doi:10.1056/NEJMra1810769
  • Pulmonary irritants- Nelson LS, Odujebe OA. Simple asphyxiants and pulmonary irritants. In: Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR, eds.Goldfrank's Toxicologic Emergencies, 11e New York, NY: McGraw-Hill; 2019.
• Incidence data
  • Gummin DD, Mowry JB, Spyker DA, et al. 2017 Annual report of the American association of poison control centers’ national poison data system (NPDS): 34th annual report. Clin Toxicol (Phila) 2017;55:1072–254.