Clinical Toxicology

ISSN: 0009-9309 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/ictx18

Nonconcordance between Clinical Impression and Laboratory Findings in Clinical Toxicology DANIEL THAU TEITELBAUM, JANET MORGAN & GAYL GRAY To cite this article: DANIEL THAU TEITELBAUM, JANET MORGAN & GAYL GRAY (1977) Nonconcordance between Clinical Impression and Laboratory Findings in Clinical Toxicology, Clinical Toxicology, 10:4, 417-422, DOI: 10.3109/15563657709046277 To link to this article: http://dx.doi.org/10.3109/15563657709046277

Published online: 25 Sep 2008.

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CLINICAL TOXICOLOGY 10(4), pp. 417-422 (1977)

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Nonconcordance between Clinical Impression and Laboratory Findings in Clinical Toxicology

DANIEL THAU TEITELBAUM, M.D.; JANET MORGAN, M.A.; and GAYL GRAY, M.A. POISONLAB Denver, Colorado

In 1969, Davidow et al. published a landmark paper entitled ?'Serendipitous Toxicologic Findings. 'I In this paper, Dr. Davidow and his colleagues pointed out the high percentage of occurrence of unexpected substances of toxicologic importance in post mortem material. Since that time several studies have confirmed the poor accuracy of clinical diagnoses of toxic disease. Each succeeding study has confirmed Davidow's assertion that I'more and/or other" drugs will be found than were suspected by the attending physician, o r pathologist, on the basis of the clinical information available to them. A recent study by Lundberg and Wohlberg confirms this work in clinical specimens obtained from the LAC-USC medical services. Since 1969, we at Poisonlab have offered a comprehensive "Coma Panel" which was designed to respond to the implications of Davidow' s original work. We have not previously reported on the findings of our work. In response to a request from IMS America, prime contractor for the DAWN project, we undertook to analyze the results of four months of our work from the Denver Metropolitan area. The purpose of this study was to provide the laboratory confirmation of the emergency room o r other clinical unit impression of drug distribution in their clinical material. During the months of March through June 1975, 450 c a s e s met the study group criteria. All patients were treated in hospitals within 417 Copyright 0 1977 hy Marcel Dekker. Inc All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means. electronic or mechanical. including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.

TEITELBAUM, MORGAN, AND GRAY

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418

the five-county Denver metropolitan area. Most of the hospitals are large, voluntary general hospitals with busy emergency services. They range from 180 to 600 beds in size. Most patients were permanent residents of the Denver area. In every case, a direct contact was made by Poisonlab with the source of the clinical sample, the emergency room physician, o r attending physician to determine his initial clinical impression of the toxic cause of the patient's illness. This contact was made within 24 h r of receipt of the sample. Certain demographic and motivational information was also obtained a t the time of this contact, which will be reported upon at a later date. No specific identifying information was sought o r reported to the DAWN project. Within the study group 260 cases requested "Coma Panels." This group of patients forms the basis of the drug distribution and diagnostic precision sections of this report. By definition, this group of cases comes from the most sophisticated group of hospitals in our specimen source area. Rural hospitals which supply close to half of Poisonlab's clinical p a t e r i a l were excluded from the study because it was difficult to obtain the first impression of the attending physician due to the distance of these hospitals from Poisonlab. It was often necessary to visit the source hospital to ferret out all of the necessary study information from the chart and from the attending personnel. No cases which originated in Poisonlab's San Diego facility are included. Female patients accounted for 268 of the samples and 168 samples were obtained from male patients. Sex information could not be obtained on 14 patients. Of the requests submitted and tests performed, 172 were for female patients and 88 were for male patients. One patient was a transsexual in the midst of s e x change operation and was recorded as male, although the genetic sex was female. The youngest female patients were 12 years of age and the eldest was 83. The youngest male patients were 10 years of age and eldest was 7 5. The age distribution of the patients involved in this overall study was plotted on a histogram. Female patients demonstrate a bimodal distribution of crisis-related drug use, while males demonstrate a single modal distribution. The male age median centered about age 29. In women c r i s e s appear to center on mean ages of 29 and 43. Further work is required to confirm these findings, butThere are obvious implications for psychiatrists, generalists, toxicologists, and information specialists, if these findings a r e confirmed. A significant number of very oung patients was noted in this series: 24% of male patients and 19 o of female patients were under 20 years of age. Drug-related disease, including addiction, suicide, and psychic dependency, persisted well into old age, in both males and females. Age distribution of the "Coma Panel" samples was similar to the distribution of the total number of samples in the study. The drugs

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CLINICAL I MPRESSION AND LABORATORY FTNDINGS

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TABLE 1. Drugs Normally Tested for in the Coma Panel (0005 Coma Panel Blood-30 m l Grey Top Urine-100 m l ) Alcohol

Homatropine

Amitriptyline/nortriptiline

Im ip r a m ine

Atropine

Meperidine

Barbiturates

Meprobamate

Chloral hydrate

Methadone

Chlo rdiaz epoxide

Me thapyrilene

C hlorp heniram ine

Methaqualone

Codeine

Meth yp ry 1on

Desipramine

Morphine

Diazepam/nordiazepam

Oxaz epa m

Diphenhydram ine

Pentazocine

Doxepin

Phenothiazines

Ethchlorvinyl

Propoxyphene/norpropoxyphene

Flurazepam

Salic ylates

Glutethimide

Scopolamine

normally tested for specifically in the Coma Panel are shown in Table 1. Each drug and/or metabolite is sought in i t s own right and i t s presence o r absence is reported. Excellent sensitivity has been achieved f o r all drugs except diazepam, for which screening techniques are less sensitive than we would like. All of these drugs and some others have been found a t least once in this clinical material. Table 2 shows the o r d e r of frequency of positive findings of the top 20 drugs. The frequency ranking of suspected drugs is shown in Table 3. While the two drug rankings are somewhat similar, i t should be noted that drugs such as diazepam and barbiturates were suspected much more often than found, and alcohol, propoxyphene/norpropoxyphene, salicylates, and the antidepressants were suspected much less often than they were found. Chloral hydrate continues to be found regularly in clinical material and is seldom suspected. Methadone was never suspected and never found in this group. When it is suspected a Dangerous Drug Panel is usually requested by the physician rather than a coma panel. Scatter analysis of cases shows that in any given case the precision of diagnosis is far poorer than overall

420

TEITELBAUM, MORGAN, AND GRAY TABLE 2

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Drug

% frequency

1. Alcohol

24

2. Salicylates 3. P ropoxy phene/no rp ropoxyphene 4. Barbiturates

17 7 6 5 5 3 3 3 3 2

5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 1 5. 16. 17.

Diazepam/nordiazepam Codeine Meprobamate Morphine Methapyrilene Phenothiazines Diphenydramine Chlordiazepoxide

2

Amit riptiline/nort riptiline

2

Methyprylon

2 2

Imipramine/desipramine Chloral hydrate Meperidine

18. Glutethimide 19. C hlo rp heni ra min e 20. Doxepin

1 1 1 1 1

94

study of the lists would suggest. E r r o r s in scope and range frequently occur. There is little perception of the clinical signs of one o r another intoxication. Often only historical factors are considered. Typical diagnostic performance in individual c a s e s is shown in Table 3. Of 260 c a s e s in which Coma Panels were requested, the drugs suspected were found in only 153 (59%), in 90 c a s e s (35%) additional drugs were found, and in 104 c a s e s (41%) the drugs suspected were not found. About 8% of the coma panels were negative for the full panel of drugs. L e s s than 2% contained other drugs which were detected and subsequently identi-

CLINICAL I MPRESSION AND LABORATORY FINDINGS TABLE 3

.c

Drug

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42 1

% ranking

1. Alcohol

18

2. Diazepam/nordiazepam

14

3. 4. 5. 6. 7.

Salic ylates

13

Barbiturates

8

Phenothiazines

6

Codeine

5 4

Flurazepam

8. Chlordiazepoxide 9. P ropoxyphene/no rpropoxyphene

4 3

10. Methapyrilene

2

11. Amitriptiline/nort riptiline

2

12. Imipramine/desipramine

2

13. Glutethimide 14. Doxepin

2

15. Meprobamate

2 1

16. Methyprylon 17. Meperidine

2

1

18. Diphenydramine

1

19. C hlorpheniramine

1

20. Heroin

1 92

fied by further analytical work. Only the consistent use of broad-based screen of high sensitivity (with the notable exception of diazepam f o r which we have not yet found a sufficiently sensitive s c r e e n ) permits adequate diagnostic precision to guide patient care in those cases in which active intervention is required. In addition, the use of the panel directs later quantitative analysis to the most productive pathways. Such quantitative follow-ups, intelligently used, can be the key to definitive treatment decisions in many critical cases. We believe that a significantly different drug distribution, and an

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TEITELBAUM, MORGAN, AND GRAY

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even lower diagnostic efficiency would be found in o u r r u r a l hospital material. By the s a m e token, we believe that lower diagnostic accur a c y would be found in urban hospitals where no emphasis on clinical toxicology comparable to that found in Denver is made. At s o m e time in the future, if adequate funds become available, we will study certain of these other populations as they occur in our clinical material.

Nonconcordance between clinical impression and laboratory findings in clinical toxicology.

Clinical Toxicology ISSN: 0009-9309 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/ictx18 Nonconcordance between Clinical Impress...
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