Chloramine

Background

  • Derivative of ammonia with substitution of 1-3 hydrogen ions by chlorine.
    • Monocholramine NH2Cl
    • Dichloramine NHCl2
    • Nitrogen trichloride NCl3
  • Inhalation causes chloramines to react with moist mucus membranes releasing ammonia, hydrogen chloride, and oxygen free radicals[1]
  • Produced with the mixing of household cleaning agents containing ammonia and bleach
    • Most common form of exposure
  • Thousands of exposures annually but few people seek medical attention as most exposures are mild.

Clinical Features

Inhalation exposure
  • Dyspnea
  • Upper airway irritation
  • Cough
  • Wheezing
  • Rarely; Stridor and upper airway edema
Complications

Differential Diagnosis

Acute dyspnea

Emergent

Pediatric-specific

Non-Emergent

Evaluation

  • History of using home cleaning agents in an enclosed space

Management

Symptoms may be worse in patient's with asthma or COPD

  • Most patients will not require any treatment
  • Consider X-ray
  • Oxygen as need for low O2 saturation
  • Albuterol
    • 2.5-5mg nebulized Q20 minutes or continuous nebulizer
  • Intravenous steroids
  • Epinephrine nebulized
    • Consider for patient's with stridor, voice changes, or continuous dyspnea despite aforementioned treatment
  • If the exposure is severe and the patient is unstable or continues to decline despite management above then consider intubation

Disposition

  • Most patients can be observed for 4-6 hours in the ED[2]
  • If asymptomatic after observation the patient can be discharged home
  • Consider repeat X-ray
  • Consider admission or in house observation for asthmatics/COPD patients or those with continued symptoms after 4-6 hours

See Also

External Links

References

  1. Tanen, David A., Kimberlie A. Graeme, and Robert Raschke. "Severe Lung Injury after Exposure to Chloramine Gas from Household Cleaners." New England Journal of Medicine N Engl J Med 341.11 (1999): 848-49. New England Journal of Medicine. Web. 16 Oct. 2015.
  2. US National Library of Medicine. TOXNET: Toxicology Data Network.