Chloroform ingestion causing severe gastrointestinal injury, hepatotoxicity and dermatitis confirmed with plasma chloroform concentrations.

CONTEXT: Poisoning due to chloroform ingestion is rare. The classic features of acute chloroform toxicity include central nervous system (CNS) and respiratory depression, and delayed hepatotoxicity. CASE DETAILS: A 30-year-old female ingested 20-30 mL of 99% chloroform solution, which caused rapid loss of consciousness, transient hypotension and severe respiratory depression requiring endotracheal intubation and ventilation. She was alert by 12 h and extubated 16 h post-overdose. At 38-h post-ingestion, her liver function tests started to rise and she was commenced on intravenous acetylcysteine. Her alanine transaminase (1283 U/L), aspartate transaminase (734 U/L) and international normalized ratio (2.3) peaked 67- to 72-h post-ingestion. She also developed severe abdominal pain, vomiting and diarrhoea. An abdominal CT scan was consistent with severe enterocolitis, and an upper gastrointestinal endoscopy showed erosive oesophagitis, severe erosive gastritis and ulceration. She was treated with opioid analgesia, proton pump inhibitors, sucralfate and total parenteral nutrition. Secretions caused a contact dermatitis of her face and back. Nine days post-ingestion she was able to tolerate food. Her liver function tests normalized and the dermatitis resolved. Chloroform was measured using headspace gas chromatograph mass spectrometry, with a peak concentration of 2.00 µg/mL, 4 h 20 min post-ingestion. The concentration-time data fitted a 1-compartment model with elimination half-life 6.5 h. DISCUSSION: In addition to early CNS depression and delayed hepatotoxicity, we report severe gastrointestinal injury and dermatitis with chloroform ingestion. Recovery occurred with good supportive care, acetylcysteine and management of gastrointestinal complications.

A comparison of emergency triage scales in triaging poisoned patients.

BACKGROUND: Triage of toxicology patients presents a challenge due to their complexity, underlying psychosocial issues, and additional pharmacological considerations. Two emergency department triage systems used in Australia, the Australasian Triage Scale (ATS) and the Manchester Triage System (MTS), were compared in triaging patients presenting with poisoning and envenoming. METHODS: In this simulation-based study, 30 triage nurses from three hospitals were given 8 tabletop scenarios and asked to provide a triage category. 20 nurses from two hospitals using the ATS, and 10 nurses from a third hospital using the MTS, triaged 8 scenarios, grouped into "commonly encountered" (n=4) and "rarely encountered" (n=4). Triage systems and scenario groups were compared for median triage category and variance in scoring. Triage nurses also noted if they would seek help from toxicology services or the poisons information centre (PIC) for advice. RESULTS: Overall, MTS nurses triaged all 8 scenarios with a lower acuity triage category, though statistically significant for only 3 scenarios. ATS nurses scored higher acuity triage category in all 4 "rare" highly toxic presentations, whereas MTS nurses scored higher acuity when vital signs were abnormal. MTS showed wider variance in triage scores in both scenario groups when compared to the ATS. Triage nurses without access to local toxicology services chose to contact PIC in most cases. CONCLUSIONS: When compared to the ATS, MTS gave a lower acuity triage score for all common and rarely encountered poisoning scenario groups, which included highly toxic ingestions that appear well at triage but may progress to severe poisoning. Triage nurses should refer to information on highly toxic exposures and envenomation guidelines during their triage risk assessment.