Chloramine

• 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.

Inhalation exposure

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

Complications

• Chemical pneumonitis
• Non cardiogenic pulmonary edema

• History of using home cleaning agents in an enclosed space

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

• 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

• Toxicology (Main)
• Inhalation exposure