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

• 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

• Chemical pneumonitis
• Non cardiogenic pulmonary edema

Differential Diagnosis

Shortness of breath

Emergent

• Pulmonary
  • Airway obstruction
  • Anaphylaxis
  • Aspiration
  • Asthma
  • Cor pulmonale
  • Inhalation exposure
  • Noncardiogenic pulmonary edema
  • Pneumonia
  • Pneumocystis Pneumonia (PCP)
  • Pulmonary embolism
  • Pulmonary hypertension
  • Tension pneumothorax
  • Idiopathic pulmonary fibrosis acute exacerbation
• Cardiac
  • Cardiac tamponade
  • Cardiogenic pulmonary edema (CHF)
  • Myocardial Infarction
  • Pericarditis
• Other Associated with Normal/↑ Respiratory Effort
  • Abdominal distension
  • Anemia
  • CO Poisoning
  • Diabetic ketoacidosis (DKA)
  • Diaphragm injury
  • Electrolyte abnormalities
  • Epiglottitis
  • Flail chest
  • Hypotension
  • Metabolic acidosis
  • Pneumonia
  • Pneumothorax/hemothorax
  • Renal Failure
  • Sepsis
  • Toxic ingestion
• Other Associated with ↓ Respiratory Effort
  • Guillain-Barre syndrome
  • Multiple sclerosis
  • Myasthenia Gravis
  • Lambert-Eaton Syndrome
  • Organophosphate toxicity
  • Stroke (Main)
  • Tick paralysis

Non-Emergent

• ALS
• Ascites
• Uncorrected ASD
• Congenital heart disease
• COPD exacerbation
• Fever
• Hyperventilation
• Neoplasm
• Obesity
• Panic attack
• Pleural effusion
• Polymyositis
• Porphyria
• Pregnancy
• Rib fracture
• Spontaneous pneumothorax
• Thyroid Disease

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
  • Dexamethasone
    • 0.6mg/kg IV or PO (max 16mg)
  • Methylprednisolone
    • Adults- 125mg IV
    • Children- 2mg/kg IV
• 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
  • Consider awake fiberoptic intubation given upper airway swelling/edema
  • Prepare for cricothyrotomy simultaneously if intubation fails

Disposition

• Most patients can be observed for 4-6 hours in the ED
• 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

• Toxicology (Main)
• Inhalation exposure

References

Authors

Colin Hoff, Daniel Ostermayer, Neil Young