Fatal ingestion of sodium hypochlorite bleach with associated hypernatremia and hyperchloremic metabolic acidosis

Ingestion of sodium hypochlorite bleach is usually benign, leading most poi son centers to advocate conservative, home management. We report a rare, fa tal case of household bleach ingestion. A 66-y-old female ingested an unkno wn quantity of regular CLOROX bleach (5.25% sodium hypochlorite, pH = 11.4) . Upon discovery, she was vomiting spontaneously, and had slurred speech an d oral mucosal discoloration. On hospital arrival the patient became unresp onsive with shallow respirations. Laboratory studies revealed hypernatremia (169 mEq Na/L), hyperchloremia (143 mEq Cl/L), and metabolic acidosis (5 m mol total CO2/L). Radiographic evaluation showed-bilateral pneumothoraces a nd pneumoperitoneum. The patient was intubated and ventilated, hypotension was treated with fluid resuscitation, and metabolic acidosis corrected with sodium bicarbonate. Naloxone and flumazenil were given without effect, and thoracostomy tubes were placed. Rapid deterioration of vital signs and men tal status ensued, with cardiorespiratory arrest from which she was resusci tated. A second cardiac. arrest resulted in death. Autopsy revealed esophag eal and gastric mucosal erosions, perforation at the gastroesophageal junct ion, and extensive necrosis of adjacent soft tissue. Stomach contents conta ined sodium hypochlorite, and pleural and peritoneal fluid had the aroma of bleach. Postmortem vitreous humor Na was 187 mEq/L and Cl was 169 mEq/L. T oxicologic analysis revealed meprobamate metabolites in the urine, and lido caine in the blood. The literature regarding fatal bleach ingestion is revi ewed.