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National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines: Recommendations for the Use of Laboratory Tests to Support Poisoned Patients Who Present to the Emergency Department

¹ Department of Pathology and Laboratory Medicine, Hartford Hospital, Hartford, CT 06102.

² Department of Emergency Medicine, Medical Toxicology, Hartford Hospital, Hartford, CT 06102.

³ Department of Clinical Laboratory Sciences, Louisiana State University Health Sciences Center, New Orleans, LA 70112.

⁴ Department of Emergency Medicine, Bellevue Hospital Center, New York, NY 10016.

⁵ Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY 14642.

⁶ Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905.

⁷ Department of Emergency Medicine, University of Cincinnati Hospital, Cincinnati, OH 45267.

⁸ Department of Pathology, Kaiser Permanente Regional Laboratory, Clackamas, OR 97015.

⁹ Department of Medical Toxicology Good Samaritan Regional Medical Center, Phoenix, AZ 85006

^aCommittee Chairman. Address for correspondence: Department of Pathology and Laboratory Medicine, Hartford Hospital, Hartford, CT 06102.

Background: Exposure to drugs and toxins is a major cause for patients’ visits to the emergency department (ED).

Methods: Recommendations for the use of clinical laboratory tests were prepared by an expert panel of analytical toxicologists and ED physicians specializing in clinical toxicology. These recommendations were posted on the world wide web and presented in open forum at several clinical chemistry and clinical toxicology meetings.

Results: A menu of important stat serum and urine toxicology tests was prepared for clinical laboratories who provide clinical toxicology services. For drugs-of-abuse intoxication, most ED physicians do not rely on results of urine drug testing for emergent management decisions. This is in part because immunoassays, although rapid, have limitations in sensitivity and specificity and chromatographic assays, which are more definitive, are more labor-intensive. Ethyl alcohol is widely tested in the ED, and breath testing is a convenient procedure. Determinations made within the ED, however, require oversight by the clinical laboratory. Testing for toxic alcohols is needed, but rapid commercial assays are not available. The laboratory must provide stat assays for acetaminophen, salicylates, co-oximetry, cholinesterase, iron, and some therapeutic drugs, such as lithium and digoxin. Exposure to other heavy metals requires laboratory support for specimen collection but not for emergent testing.

Conclusions:Improvements are needed for immunoassays, particularly for amphetamines, benzodiazepines, opioids, and tricyclic antidepressants. Assays for new drugs of abuse must also be developed to meet changing abuse patterns. As no clinical laboratory can provide services to meet all needs, the National Academy of Clinical Biochemistry Committee recommends establishment of regional centers for specialized toxicology testing.

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