a) Generic: Oral liquid 0.12%; oral solution 0.12%; solution 20%; topical solution 4%
b) Aplicare antiseptic chlorhexidine gluconate: Topical solution 2% and 4%
c) Betasept: Topical liquid 4%
d) Chlorhexidine gluconate: Oral solution 0.12%
e) Dyna-Hex2: Topical liquid 2%
f) Dyna-Hex: Topical liquid 4%
g) Hibiclens: Topical liquid 4%; topical solution 4%
h) Hibistat: Topical pad 0.5%
i) Operand chlorhexidine gluconate: Topical liquid 2% and 4%
j) Peridex: Oral liquid 0.12%
k) Periochip: Mucous membrane chip 2.5 mg
l) Periogard: Oral liquid 0.12%

1) Concentrations greater than 2% may be irritating to the skin. Contact dermatitis, photosensitivity (with prolonged use), urticaria, and anaphylactoid reactions have also been reported. Tooth discoloration, altered taste sensation, superficial desquamation, idiosyncratic desquamation, ulceration of the oral mucosa, and taste disturbance have been reported in patients using chlorhexidine 0.12% mouthwash. Malaise, fatigue, nausea, and depression developed in 3 patients receiving continuous pleural irrigation with approximately 5 L/day of 0.02% chlorhexidine (1 gram/day of chlorhexidine).
2) Some chlorhexidine topical solutions may contain isopropyl alcohol. Please refer to "Isopropyl alcohol" document for exposure information.

1) Little data exist on inadvertent or deliberate oral exposure to chlorhexidine salts. Little systemic absorption occurs, thus the primary expected effect is irritation in lower concentrations and corrosive effects in larger concentrations.
2) HEENT: Concentrations of up to 0.2% are tolerated by the eye. Eye irritation, corneal edema and injury, opacities, and conjunctivitis have been reported with exposure to 4% solution. Instillation into ears of patients with non-intact tympanic membranes, such as those with tympanostomy tubes, has caused hearing loss.
3) INGESTION: Ingestion of 150 mL of a 20% chlorhexidine gluconate solution (30 grams of chlorhexidine or 400 mg/kg) resulted in pharyngeal edema, necrotic esophageal lesions, elevated liver enzymes, and diffuse fatty degeneration and lobular necrosis of the liver. Ingestion of 30 mL of a 4% solution did not result in adverse gastrointestinal effects. Ingestion of 0.12% mouth rinse is not expected to be irritating.
4) INTRAVENOUS: Inadvertent intravenous administration of 0.8 gram of 20% chlorhexidine gluconate resulted in hypotension, tachycardia, and acute respiratory distress syndrome. Hemolysis due to hypotonicity has been reported following accidental intravenous administration of 1 L of 1:5000 chlorhexidine.
5) OTHER ROUTES: Hematuria has been reported following bladder irrigation. Acute ulcerative colitis has been described following an enema containing 10 mL of Hibiclens skin cleaner(R) (4% chlorhexidine) mixed in 2 L of tap water. Bradycardia was noted in a newborn breastfeeding infant after oral exposure to a chlorhexidine spray which was used on the mother's nipples to prevent mastitis. Methemoglobinemia may occur following exposure to para-chloraniline, a chlorhexidine decomposition production. Three cases of severe methemoglobinemia were observed in premature neonates when chlorhexidine gluconate was accidentally used as humidifying fluid in a new type of incubator.

1) Treatment is symptomatic and supportive. Little systemic absorption occurs, thus the primary expected effect following an ingestion is irritation in lower concentrations and corrosive effects in larger concentrations (20% solution). Following an ingestion of 20% solution, each patient should be examined for mucosal damage. There is little information regarding the use of endoscopy, corticosteroids or surgery in the setting of concentrated chlorhexidine salts ingestion. The following information is derived from experience with other corrosives. Perform endoscopy early (within 12 hours) in patients with stridor, drooling, vomiting, significant oral burns, and difficulty swallowing or abdominal pain. If burns are absent or grade I severity, patient may be discharged when able to tolerate liquids and soft foods by mouth. If mild grade II burns, admit for intravenous fluids, slowly advance diet as tolerated.

1) Inadvertent intravenous administration of 0.8 gram of 20% chlorhexidine gluconate resulted in hypotension, tachycardia, and acute respiratory distress syndrome. Early airway management in patients with acute respiratory distress. Early (within 12 hours), perform a gastrointestinal endoscopy to evaluate for burns. Treat hypotension with fluids, vasopressors if needed.

1) INGESTION: Patients with ingestions of low concentration products should rinse the mouth with water. In patients with ingestions of high concentration products without vomiting or respiratory distress who are able to swallow, dilute with 4 to 8 oz milk/water if possible shortly after ingestion; then NPO until after endoscopy. Neutralization, gastric lavage, and activated charcoal are not indicated.
2) OCULAR: Concentrations of up to 0.2% are tolerated by the eye. Eye irritation, corneal edema and injury, opacities, and conjunctivitis have been reported with exposure to 4% solution. Irrigate exposed eyes with water.
3) DERMAL: Concentrations greater than 2% may be irritating to the skin. Remove contaminated clothes, follow with copious irrigation.
4) INHALATION: Humidified oxygen.

1) Aggressive airway management in patients with any indication of upper airway injury.

1) Should be performed as soon as possible (preferably within 12 hours, not more than 24 hours) in any patient with ingestion of a 20% solution, patients with deliberate ingestion of large amounts, adults with any signs or symptoms attributable to inadvertent ingestion, and in children with stridor, vomiting, or drooling after inadvertent ingestion. Endoscopy should also be considered in children with dysphagia or refusal to swallow, significant oral burns, or abdominal pain after unintentional ingestion. Children and adults who are asymptomatic after inadvertent ingestion do not require endoscopy. The grade of mucosal injury at endoscopy is the strongest predictive factor for the occurrence of systemic and GI complications and mortality. The absence of visible oral burns does NOT reliably exclude the presence of esophageal burns.

1) The use of corticosteroids to prevent stricture formation is controversial. Corticosteroids should not be used in patients with grade I or grade III injury, as there is no evidence that they are effective. Evidence for grade II burns is conflicting, and the risk of perforation and infection is increased with steroid use, so routine use is not recommended.

1) Copious irrigation until pH neutral; perform slit lamp exam. Ophthalmology consult. Antibiotics may be indicated.

1) HOME CRITERIA: A patient with an inadvertent exposure, that remains asymptomatic can be managed at home.
2) OBSERVATION CRITERIA: Patients deliberate ingestion, symptoms or ingestion of a high concentration (20%) product should be sent to a healthcare facility for evaluation. Patients who remain asymptomatic over 4 to 6 hours of observation, and those with endoscopic evaluation that demonstrates no burns or only minor grade I burns, and who can tolerate oral intake can be discharged home.
3) ADMISSION CRITERIA: Symptomatic patients, and those with endoscopically demonstrated grade II or higher burns should be admitted. Patients with respiratory distress, grade III burns, hemodynamic instability, and gastrointestinal bleeding should be admitted to an intensive care setting.
4) CONSULT CRITERIA: Consult a poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear. Consult a gastroenterologist for endoscopic evaluation of any patient with concern for corrosive GI injury.

1) The absence of oral burns does NOT reliably exclude the possibility of significant esophageal burns.
2) Patients may have severe tissue necrosis and impending perforation requiring early surgical intervention without having severe hypotension, rigid abdomen, or radiographic evidence of intraperitoneal air.
3) Patients with any evidence of upper airway involvement require early airway management before airway edema progresses.
4) The extent of eye injury may not be apparent for 48 to 72 hours after the burn. All patients with corrosive eye injury should be evaluated by an ophthalmologist.

1) Ingestion or another irritant, or and acid or base, gastrointestinal hemorrhage, or perforated viscus.

1) DECONTAMINATION: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).

1) TOOTH DISCOLORATION: Chlorhexidine mouthwashes may discolor teeth and tongue a black or brown color (Addy & Moran, 1984; Prayitno & Addy, 1979; Jensen, 1977; Eriksen & Gjermo, 1973).
2) Altered taste sensation has been noted after use in dentistry (Flotra et al, 1971).
3) Superficial desquamation has been noted after dental rinsing with chlorhexidine (Skoglund & Holst, 1982).

1) CONJUNCTIVITIS has been noted in some patients who used a soft contact lens solution with chlorhexidine (Van Ketel & Melzer-van Riemsdijk, 1980; Mondino et al, 1982).

1) IRRITATION
2) CORNEAL EDEMA: Presumed accidental preoperative ocular exposure to Hibiclens(R) produced corneal edema in 5 patients. Corneal edema resolved over 6 months in 3 patients, leaving mild stromal scarring and reduced endothelial cell counts. Corneal edema progressed to diffuse bullous keratopathy, which required penetrating keratoplasty in 2 patients (Phinney et al, 1988).
3) CORNEAL INJURY: Bilateral eye redness, pain, diminished vision from severe corneal injury requiring corneal transplant, and epithelial corneal defect were noted. These effects were described in a report of 4 cases in which chlorhexidine gluconate used for preparing facial skin prior to surgical incision accidentally got into the eyes (Tabor et al, 1989).
4) CORNEAL OPACITIES: Severe and permanent corneal opacification has been observed after inadvertent ocular exposure to a 4% chlorhexidine gluconate solution (Hibiclens(R)) (Hamed et al, 1987).

1) DEAFNESS: Chlorhexidine has been reported to cause deafness when instilled into the middle ear through a perforated eardrum (Prod Info Hibiclens(R), chlorhexidine, 2000). Sensorineural deafness was reported following application to the inner ear (Bicknell, 1971).

1) ORAL MUCOSA CHANGES: Therapeutic use of a mouthwash containing 0.2% chlorhexidine has resulted in idiosyncratic desquamation and ulceration of the oral mucosa (Skoglund & Holst, 1982).
2) TASTE DISTURBANCE is a potential adverse reaction from chlorhexidine mouthwashes. A bitter aftertaste may occur for up to several hours after use. Rare instances of permanent taste alterations have been reported (Prod Info Peridex(R), chlorhexidine, 2000).

1) BURNS: Caustic burns of the lips, mouth, and tongue occurred within minutes of being accidentally fed a dilute antiseptic solution of chlorhexidine 0.05% and cetrimide 1% in 5 previously healthy newborn breast fed infants (Mucklow, 1988).

1) WITH POISONING/EXPOSURE

1) WITH POISONING/EXPOSURE

1) WITH POISONING/EXPOSURE

1) CASE REPORT: A 67-year-old man, with rectal cancer, developed acute respiratory distress after inadvertently receiving 0.8 gram (13 mg/kg) of 20% chlorhexidine gluconate intravenously instead of a muscle relaxant prior to undergoing a surgical procedure. Over the next three hours, the patient developed tachycardia, (pulse 120 bpm), hypotension (70/35 mmHg), and tachypnea (32 breaths/minute). A chest x-ray revealed bilateral alveolar infiltrations, suggestive of acute respiratory distress syndrome. O2 saturation was 92% on 100% oxygen by rebreathing mask, necessitating mechanical ventilation. Despite 3 cycles of plasma exchange therapy, the patient's condition continued to deteriorate with a repeat chest x-ray demonstrating worsening alveolar infiltrations. Following treatment with extracorporeal membrane oxygenation (ECMO) over a 72-hour period, the patient's respiratory status improved. Twelve weeks post-exposure, the patient underwent a colectomy with lymph node dissection, with an uneventful recovery. He was subsequently discharged without sequelae (Ishigami et al, 2001).
2) CASE SERIES: Pulmonary edema was described in one of five infants accidentally fed a dilute antiseptic solution of chlorhexidine 0.05% and cetrimide 1% (Mucklow, 1988).

1) CASE SERIES: Occupational asthma was seen in 2 nurses exposed to chlorhexidine/alcohol disinfectants. Both cases were confirmed by challenge testing, which resulted in immediate, but not delayed, responses (Waclawski et al, 1989).

1) CASE SERIES: Malaise, fatigue, nausea, and depression were described in 3 patients receiving continuous pleural irrigation with approximately 5 liters/day of 0.02% chlorhexidine (1 gram/day of chlorhexidine) (Friis-Moller et al, 1984).

1) WITH THERAPEUTIC USE

1) Pharyngeal edema and necrotic esophageal lesions were described following ingestion of 150 mL of a 20% concentrated chlorhexidine solution (Massano et al, 1982).

1) Acute ulcerative colitis has been described following an enema containing 10 mL of Hibiclens skin cleaner(R) (4% chlorhexidine) mixed in 2 liters of tap water (Hardin & Tedesco, 1986).

1) WITH POISONING/EXPOSURE

1) Hematuria has been reported following bladder irrigation (Cheung & O'Leary, 1985).

1) WITH POISONING/EXPOSURE

1) WITH POISONING/EXPOSURE

1) WITH THERAPEUTIC USE

1) Concentrations of the gluconate salt greater than 2% may be irritating (Foulkes, 1973).

1) Acute contact urticaria has been reported.

1) WITH THERAPEUTIC USE

1) WITH POISONING/EXPOSURE

1) CASE REPORT: A 66-year-old man was found to exhibit both delayed and immediate-type hypersensitivity reactions to chlorhexidine gluconate at concentrations as low as 0.005% (Bergqvist-Karlsson, 1988).

1) FIXED DRUG REACTION: A 46-year-old with numerous other allergies and a previous history of fixed drug reactions to aspirin and barbiturates developed one to chlorhexidine 0.12% after subgingival irrigation. She developed pruritus and red rashes on the palms of her hands and soles of her feet (Moghadam et al, 1991).

1) RATS - Chlorhexidine was not teratogenic in rats (Gilman & DeSalva, 1979; (Case, 1977).

1) To date, no reports of teratogenic, developmental, or other adverse effects have been reported in women exposed to topical chlorhexidine during pregnancy (Personal Communication, 1984).
2) Based on negligible topical absorption and a complete lack of any unusual reported effects when used during pregnancy, chlorhexidine would NOT appear to present a risk to pregnant women.

1) Para-chloraniline (PCA) is present as a contaminant in all preparations containing chlorhexidine. PCA has been suggested to be a potential carcinogen.

A) Symptomatic patients, and those with endoscopically demonstrated grade II or higher burns should be admitted. Patients with respiratory distress, grade III burns, hemodynamic instability, and gastrointestinal bleeding should be admitted to an intensive care setting.

A) A patient with an inadvertent exposure, that remains asymptomatic can be managed at home.

A) Consult a poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear. Consult a gastroenterologist for endoscopic evaluation of any patient with concern for corrosive GI injury.

A) Patients deliberate ingestion, symptoms or ingestion of a high concentration (20%) product should be sent to a healthcare facility for evaluation. Patients who remain asymptomatic over 4 to 6 hours of observation, and those with endoscopic evaluation that demonstrates no burns or only minor grade I burns, and who can tolerate oral intake can be discharged home.

1) If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. The exact ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
2) USE OF DILUENTS IS CONTROVERSIAL: While experimental models have suggested that immediate dilution may lessen caustic injury (Homan et al, 1993; Homan et al, 1994a; Homan et al, 1995), this has not been adequately studied in humans.
3) DILUENT TYPE: Use any readily available nontoxic, cool liquid. Both milk and water have been shown to be effective in experimental studies of caustic ingestion (Maull et al, 1985; Rumack & Burrington, 1977; Homan et al, 1995; Homan et al, 1994a; Homan et al, 1993).
4) ADVERSE EFFECTS: Potential adverse effects include vomiting and airway compromise (Caravati, 2004).
5) CONTRAINDICATIONS: Do NOT attempt dilution in patients with respiratory distress, altered mental status, severe abdominal pain, nausea or vomiting, or patients who are unable to swallow or protect their airway. Diluents should not be force fed to any patient who refuses to swallow (Rao & Hoffman, 2002).

1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).

1) INDICATIONS: Consider insertion of a small, flexible nasogastric tube to aspirate gastric contents after large, recent ingestion of caustics. The risk of worsening mucosal injury (including perforation) must be weighed against the potential benefit.
2) PRECAUTIONS:

1) No specific laboratory tests are necessary unless otherwise clinically indicated.
2) Following an ingestion of a 20% solution, monitor vital signs, serum electrolytes, renal function and liver enzymes in symptomatic patient.
3) Following an ingestion of a 20% solution, monitor for gastrointestinal burns and respiratory distress.
4) Monitor arterial blood gases, pulse oximetry, and pulmonary function tests, and obtain a chest x-ray in any patient with respiratory symptoms.

1) Patients who have ingested a 20% concentration may benefit from immediate oral dilution.
2) Do not exceed 8 ounces in adults and 4 ounces in children (Consensus, 1988), as vomiting may occur with excessive fluid. Contraindications include perforations and patients at risk of vomiting. Keep patient NPO following initial dilution until after medical/surgical evaluation.

1) Because a 4% solution produced reversible eye damage in rabbits and was mildly irritating to the skin, it is expected that ingestions would produce irritation.
2) No gastrointestinal irritation was seen in an 89-year-old woman who ingested 30 mL of a 4% solution (Emerson & Pierce, 1988). Corrosive effects have been seen with ingestion of a 20% solution.
3) Each patient should be examined for mucosal damage. Except under unusual circumstances, esophagoscopy should not be necessary. There is little information regarding the use of endoscopy, corticosteroids or surgery in the setting of concentrated chlorhexidine salts ingestion. The following information is derived from experience with other corrosives.

1) SUMMARY: Obtain consultation concerning endoscopy as soon as possible, and perform endoscopy within the first 24 hours when indicated.
2) INDICATIONS: Endoscopy should be performed in adults with a history of deliberate ingestion, adults with any signs or symptoms attributable to inadvertent ingestion, and in children with stridor, vomiting, or drooling after unintentional ingestion (Crain et al, 1984). Endoscopy should also be performed in children with dysphagia or refusal to swallow, significant oral burns, or abdominal pain after unintentional ingestion (Gaudreault et al, 1983; Nuutinen et al, 1994). Children and adults who are asymptomatic after accidental ingestion do not require endoscopy (Gupta et al, 2001; Lamireau et al, 2001; Gorman et al, 1992).
3) RISKS: Numerous large case series attest to the relative safety and utility of early endoscopy in the management of caustic ingestion.
4) The risk of perforation during endoscopy is minimized by (Zargar et al, 1991):
5) GRADING
6) FOLLOW UP - If burns are found, follow 10 to 20 days later with barium swallow or esophagram.
7) SCINTIGRAPHY - Scans utilizing radioisotope labelled sucralfate (technetium 99m) were performed in 22 patients with caustic ingestion and compared with endoscopy for the detection of esophageal burns. Two patients had minimal residual isotope activity on scanning but normal endoscopy and two patients had normal activity on scan but very mild erythema on endoscopy. Overall the radiolabeled sucralfate scan had a sensitivity of 100%, specificity of 81%, positive predictive value of 84% and negative predictive value of 100% for detecting clinically significant burns in this population (Millar et al, 2001). This may represent an alternative to endoscopy, particularly in young children, as no sedation is required for this procedure. Further study is required.
8) MINIPROBE ULTRASONOGRAPHY - was performed in 11 patients with corrosive ingestion . Findings were categorized as grade 0 (distinct muscular layers without thickening, grade I (distinct muscular layers with thickening), grade II (obscured muscular layers with indistinct margins) and grade III (muscular layers that could not be differentiated). Findings were further categorized as to whether the worst appearing image involved part of the circumference (type a) or the whole circumference (type b). Strictures did not develop in patients with grade 0 (5 patients) or grade I (4 patients) lesions. Transient stricture formation developed in the only patient with grade IIa lesions, and stricture requiring repeated dilatation developed in the only patient with grade IIIb lesions (Kamijo et al, 2004).

1) CORROSIVE INGESTION/SUMMARY: The use of corticosteroids for the treatment of caustic ingestion is controversial. Most animal studies have involved alkali-induced injury (Haller & Bachman, 1964; Saedi et al, 1973). Most human studies have been retrospective and generally involve more alkali than acid-induced injury and small numbers of patients with documented second or third degree mucosal injury.
2) FIRST DEGREE BURNS: These burns generally heal well and rarely result in stricture formation (Zargar et al, 1989; Howell et al, 1992). Corticosteroids are generally not beneficial in these patients (Howell et al, 1992).
3) SECOND DEGREE BURNS: Some authors recommend corticosteroid treatment to prevent stricture formation in patients with a second degree, deep-partial thickness burn (Howell et al, 1992). However, no well controlled human study has documented efficacy. Corticosteroids are generally not beneficial in patients with a second degree, superficial-partial thickness burn (Caravati, 2004; Howell et al, 1992).
4) THIRD DEGREE BURNS: Some authors have recommended steroids in this group as well (Howell et al, 1992). A high percentage of patients with third degree burns go on to develop strictures with or without corticosteroid therapy and the risk of infection and perforation may be increased by corticosteroid use. Most authors feel that the risk outweighs any potential benefit and routine use is not recommended (Boukthir et al, 2004; Oakes et al, 1982; Pelclova & Navratil, 2005).
5) CONTRAINDICATIONS: Include active gastrointestinal bleeding and evidence of gastric or esophageal perforation. Corticosteroids are thought to be ineffective if initiated more than 48 hours after a burn (Howell, 1987).
6) DOSE: Administer daily oral doses of 0.1 milligram/kilogram of dexamethasone or 1 to 2 milligrams/kilogram of prednisone. Continue therapy for a total of 3 weeks and then taper (Haller et al, 1971; Marshall, 1979). An alternative regimen in children is intravenous prednisolone 2 milligrams/kilogram/day followed by 2.5 milligrams/kilogram/day of oral prednisone for a total of 3 weeks then tapered (Anderson et al, 1990).
7) ANTIBIOTICS: Animal studies suggest that the addition of antibiotics can prevent the infectious complications associated with corticosteroid use in the setting of caustic burns. Antibiotics are recommended if corticosteroids are used or if perforation or infection is suspected. Agents that cover anaerobes and oral flora such as penicillin, ampicillin, or clindamycin are appropriate (Rosenberg et al, 1953).
8) STUDIES

1) In severe cases of gastrointestinal necrosis or perforation, emergent surgical consultation should be obtained. The need for gastric resection or laparotomy in the stable patient is controversial (Chodak & Passaro, 1978; Dilawari et al, 1984).
2) LAPAROTOMY/LAPAROSCOPY - Early laparotomy or laparoscopy should be considered in patients with endoscopic evidence of severe esophageal or gastric burns after acid ingestion to evaluate for the presence of transmural gastric or esophageal necrosis (Estrera et al, 1986; Meredith et al, 1988; Wu & Lai, 1993). Emergent laparotomy should be strongly considered in any patient with hypotension, altered mental status, or acidemia (Hovarth et al, 1991).

1) EVALUATION
2) MEDICAL FACILITY IRRIGATION
3) MINOR INJURY
4) SEVERE INJURY
5) SURGICAL THERAPY

a) Up to 2 grams daily by mouth for 7 days have been taken experimentally (Rushton, 1977).
b) Accidental ingestion of 30 mL of a 4% solution (equivalent to 15.18 mg/kg of chlorhexidine) in combination with 4% isopropanol resulted in mild symptoms of giddiness, unusual laughter, and increased appetite in a 59-year-old woman. No gastrointestinal symptoms were noted (Emerson & Pierce, 1988).

a) Ingestion of 400 mg/kg has resulted in hepatotoxicity (Massano et al, 1982).
b) Inadvertent intravenous administration, in a 67-year-old man, of 0.8 gram of 20% chlorhexidine gluconate resulted in the development of acute lung injury and hypotension. The patient gradually recovered following treatment with extracorporeal membrane oxygenation over a 72-hour period (Ishigami et al, 2001).

a) Infants accidentally fed a dilute antiseptic solution of chlorhexidine 0.05% and cetrimide 1% developed frothy edema and ulcers of the cheek, gums, and tongue. One infant developed acute pulmonary edema (Mucklow, 1988).

1) 1800 mg/kg