Analytical role in clinical toxicology: impact on the diagnosis and treatment of poisoned patients1

Abstract

AbstractAcute poisoning is a medical emergency situation and requires urgent but adequate medical intervention. The outcome depends on accurate primary care, the correct identification of poison(s) and adequate therapeutic decisions. The present paper reviews the literature concerning the role of analytical toxicology in emergency medicine with particular focus on the last few years. This study is mainly based on a PubMed search: “clinical toxicology review (urine, serum)”. Many acutely poisoned patients are treated with no laboratory support other than general clinical chemistry, haemostaseology and haematology. Emergency toxicological analyses that could influence immediate patient management, if offered on the basis of 24-h availability, are most often restricted to ethanol, oximetry and drugs of abuse in urine. Despite paracetamol (acetaminophen) being the top entry on all hit lists of poison control centres worldwide with few exceptions, the availability of its determination in blood on an urgent basis is not standard even at hospitals with large accident and emergency departments. Therefore, recommendations regarding the assays and methods that should be provided locally and at regional centres were provided for the US and UK, and should be adapted for Germany. Emergency toxicological analyses that could influence immediate patient management are relatively few in number and are remarkably similar worldwide. Recommendations for the US and UK are compared in the present paper together with suggestions for Germany. The first group of these assays should be provided locally by larger hospitals with emergency and intensive care units with a turnaround time (TAT) of <1 h. Other assays (second group) and a systematic toxicological analysis that can help improve patient management after a period of primary stabilisation of vital functions and general supportive therapy can be provided from regional centres with a TAT of 4 h. The need for such centres and the repertoire of tests and methods that should be available will be adapted and discussed. It is well known that comprehensive toxicological analysis incorporating various methods can identify much more substances than are clinically suspected. At the same time, this information might have no clinical utility owing to the time required for sampling, transportation, analysis and reporting, or because the toxicological report might be inconsequential. This has contributed to a range of clinical opinions and practices, from a minimalist approach to a “shotgun” approach of broad-based laboratory testing. The present review should help to understand and discuss the pros and cons of both approaches.