A report about three women who nearly died because they mixed ammonia-based cleaners and laundry bleach has brought renewed warnings by poison experts of the potentially deadly dangers of combining seemingly innocuous household products.
And at the same time, poison center officials in Los Angeles and Denver agreed that reactions, ranging from nose and throat irritation to death, are so common among victims of such inadvertent chemical accidents that they are an almost daily occurrence.
Household cleaner poisoning incidents can occur with so little warning, experts agreed, that the only safe approach is never to mix cleaning agents, no matter how harmless the combination may seem or how similar--as in the case of ammonia cleaner and bleach--the products may smell or otherwise seem to the lay person.
Reports of Deaths
Adding significance to the medical journal report, Dr. Barry Rumack, head of the Rocky Mountain Poison Control Center, said in a telephone interview that there have been at least three deaths from such cleaning agent reactions in the last two years, and calls about less serious outcomes are commonplace. The Rocky Mountain center is perhaps the nation's most prominent poison control facility.
A spokesman for the poison control center operated by the Los Angeles County Medical Assn. said telephone inquiries from the public resulting from exposure to such mixture reactions are received daily.
Despite the common nature of such unintended poisonings, however, two doctors at the University of Missouri School of Medicine in Kansas City report in the current issue of the journal, Chest, that doctors remain insufficiently aware of the possible symptoms in such cases. The two physicians speculated that many cases of mixed cleaner-caused toxic pneumonitis--a potentially catastrophic impairment of the lungs--are misdiagnosed in the nation's emergency rooms every year.
At issue are two chemical phenomena that for the last 10 years have been widely recognized among poison experts as dangerous, Rumack said.
The first of the two reactions was the cause of the three new cases reported in Chest by Drs. George Reisz and Roger Gammon of the University of Missouri's pulmonary division. In all three cases, women cleaning their homes had mixed bleach and ammonia cleaners together, believing that the combination would improve results.
Instead, the women involved cleaned for several hours in small rooms with little ventilation--not realizing that slight differences in the chemistry of ammonia cleaners and bleach lead to a reaction when the two are combined that produces a gas called chloramine, which can quickly have potentially deadly effects.
In one case, the victim continued cleaning even though a young man helping her stopped almost immediately, complaining of eye, nose and throat irritation. All three women eventually collapsed and were taken to hospitals by paramedics. In the emergency room, doctors mistook the symptoms for signs of respiratory distress unrelated to chemical exposure in all cases.
All three eventually recovered, but they had average hospital stays of nearly 27 days.
The second potentially disastrous reaction involves mixing bleach with acid-based toilet bowl cleaners--of any brand containing the chemical sodium bisulfate. When those two are mixed, yet another chemical reaction in which chlorine gas--somewhat different from but just as lethal as chloramine--is released.
Rumack said ammonia cleaners that contain 5% to 10% aqueous ammonia and bleaches that contain about 5.25% sodium hypochlorite are capable of the dangerous reactions. Rumack noted that toilet bowl cleaners, bleaches and ammonia products generally all list ingredients on the package, making it possible for consumers to avoid the dangerous mixtures.
Rumack said people doing household cleaning often try toilet bowl cleaners first, but that often they are dissatisfied with the results and pour in bleach, thinking the bowl will turn a more sparkling white. Instead, the toilet bowl becomes the site of a vigorous chemical reaction that releases a gas more powerful than some of the poison gases used in World War I, he said.
"It's a pretty widespread problem," Rumack said in a telephone interview, "and we see it fairly frequently.
"The basic message is to use one cleaner at a time and don't mix them. You can really be playing with very powerful chemistry."
Worsening the problem, Rumack said, is the common use of household cleaners in bathrooms, which are often comparatively small spaces with poor ventilation. Bathroom-sized rooms trap gases released in the unintended reactions in unusually high concentrations, he said.
Nevertheless, the University of Missouri team said doctors in community hospitals who lack the benefit of experience in a poison control center may be misdiagnosing large numbers of unrecognized household cleaner cases--further understating the total incidence. "Given the rarity of previous reports (in medical journals), either we have seen an uncharacteristically high incidence or this entity is unsuspected and frequently misdiagnosed," the two doctors concluded.
"Because none of the admitting physicians in our three cases made the correct diagnosis initially, we believe the latter."