National Academy of Clinical Biochemistry
RECOMMENDATIONS FOR THE USE OF LABORATORY TESTS TO SUPPORT THE IMPAIRED
AND OVERDOSED PATIENT FROM THE EMERGENCY DEPARTMENT
We invite all with interest in Laboratory
Support for Emergency Toxicology to review this draft Laboratory Medicine
Practice Guideline (LMPG). Your comments, suggestions, additions
(including new references) and deletions are welcomed and
may be e-mailed to Dr. Alan Wu,
Chairman. Please annotate your responses with the section,
subsection and the paragraph in the draft document. You are an
important part of this process; your comments are important. Please
include your name and title with your comments so that you can be properly
credited in the final produce. These Draft Guidelines
and suggestions for improvements will be discussed at the 2001 Annual
Meeting of the American Association for
Clinical Chemistry in Chicago, IL, July 29-August 2, 2001).
Alan H. B. Wu, Chair
Department of Pathology and Laboratory Medicine, Hartford Hospital,
Hartford CT 06102
Larry A. Broussard
Department of Medical Technology, Louisiana State University Medical
Center, New Orleans, LA 70112
Robert S. Hoffman
Department of Emergency Medicine, Bellevue Hospital Center, New York, NY
Tai C. Kwong
Department of Pathology and Laboratory Medicine, and Emergency Medicine,
University of Rochester Medical Center, Rochester, NY 14642
Department of Emergency Medicine, Medical Toxicology, Hartford Hospital,
Hartford, CT 06102
Thomas P. Moyer
Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester,
Edward M. Otten
Department of Emergency Medicine, University of Cincinnati Hospital,
Cincinnati, OH 45267
Shirley L. Welch
Department of Pathology, Kaiser Permanente Regional Laboratory, Clackamas,
Emergency Medicine, University of Rochester Medical Center, Rochester, NY
from the Drug Abuse Warning Network (DAWN) have shown that a significant
number of emergency department visits are associated with the presence of
alcohol and drugs as indicated by a positive laboratory test (2).
Table 1 lists results for the first half of 1998. The statistics refer to
patients aged 6 to 97 years, whose primary presenting problem was
associated with drug use, but was not necessarily the sole reason for the
ED visit. This database is
also not a measure of drug prevalence in the general population.
Moreover, these statistics are based on self-reporting by the user,
and were not necessarily confirmed by laboratory testing.
Some drugs (e.g., cocaine and heroin) may have a higher association
with ED visits than others because they result in greater acute toxicity.
Alcohol is not separately tabulated by DAWN. However, the National
Hospital Ambulatory Medical Care Survey estimates an alcohol incidence of
27% of ED patients (3).
Together, these data indicate that nearly thirty million ED visits
per year are associated with some form of drug use.
This is the ninth in the series of Laboratory Medicine Practice Guidelines
(formerly Standards of Laboratory Practice, SOLP) sponsored by the
National Academy of Clinical Biochemistry (NACB).
An expert committee of emergency department (ED) physicians and
clinical laboratory medicine toxicologists was assembled and prepared
recommendations on the use of clinical laboratory tests to support the
drug-impaired, or overdosed patient, or those exposed to various
substances (clinical toxicology). Particular
reference is made to the management of these patients who present to
hospitals and emergency departments.
Excluded from these discussions were drug testing conducted for the
workplace, forensic and medical examiner toxicology, athletic drug
testing, and testing for various compliance programs (criminal justice,
psychiatric, physician health, etc).
Many of these other programs are guided by other recommendations
and regulations, such as the Substance Abuse and Mental Health Services
Administration, the American Academy of Forensic Sciences, International
Olympic Committee, etc. Recommendations
for detection of drugs from newborns exposed during the intrauterine
period were discussed in a previous NACB SOLP (1)
and will not be repeated. Some
of the recommendations contained herein are specifically directed towards
manufacturers of immunoassay reagents.
It is hoped that by documenting a clinical need for modified
immunoassays, manufacturers would be willing to develop these new assays.
Table 1. Estimated
Number of ED Drug Episodes and Drug mentions, January-June, 1998.a
Drug or Class
of Total ED Visits
(acetaminophen, aspirin, ibuprofen, propoxyphene, oxycodone,
(alprazolam, diazepam, lorazepam, clonazepam, triazolam)
antidepressants (amitriptyline, doxepin, imipramine)
(phenobarbital, over-the-counter sleep aids)
(amphetamine and methamphetamine)
aFrom the Office of Applied
Statistics, the Drug Abuse Warning Network, 1998. Total ED visits: 44,836,000; number of drug episodes: 272,770
(0.61%) , drug mentions: 493,096 (1.1%).
are other substances that can contribute to significant acute clinical
problems for which the laboratory might play an important role. Some of these are tabulated each year by the Toxic Exposure
Surveillance System (TESS) of the American Association of Poison Control
Centers (4). In 1998, for example, there were a reported 13,000 exposures
to organophosphates, 18,000 to rodenticides (anticoagulants), 13,000 to
heavy metals, 17,000 to carbon monoxide, and 2,000 to toluene.
It should be noted that the majority of these exposures were
managed in a non-health care facility, usually at the site of exposure.
guidelines cover five major parts: recommendations for drug testing to
support emergency department toxicology, analytical and reporting issues
for drugs of abuse testing, breath alcohol analysis, serum testing of
ethyl alcohol and other volatiles, and assays for substance abuse and
exposure. Each of these
topics opens with some background information, followed by the
recommendations themselves, and discussion of the rationale for each
recommendation. These recommendations will be presented in open forum during
Edutrak Sessions at the American Association for Clinical Chemistry Annual
Meeting on August 1st -2nd, 2001 in Chicago, IL, and
possibly the American College of Medical Toxicologists in September
2001 in Montreal. Participants to each meeting will be able to discuss the
merits of each recommendation. Each
recommendation will be graded according to the degree of consensus reached
by the discussants of these conferences.
Revisions to these recommendations and the discussion by
participants will be made prior to the submission of the final guideline