Do rapid comprehensive urine drug screens change clinical management in children?

Acute opioid overdose in pediatric patients

Recent increases in pediatric and adolescent opioid fatalities mandate an urgent need for early consideration of possible opioid exposure and specific diagnostic and management strategies and interventions tailored to these unique populations. In contrast to adults, pediatric methods of exposure include accidental ingestions, prescription misuse, and household exposure. Early recognition, appropriate diagnostic evaluation, along with specialized treatment for opioid toxicity in this demographic are discussed. A key focus is on Naloxone, an essential medication for opioid intoxication, addressing its unique challenges in pediatric use. Unique pediatric considerations include recognition of accidental ingestions in our youngest population, critical social aspects including home safety and intentional exposure, and harm reduction strategies, mainly through Naloxone distribution and education on safe medication practices. It calls for a multifaceted approach, including creating pediatric-specific guidelines, to combat the opioid crisis among children and to work to lower morbidity and mortality from opioid overdoses.

Urine Toxicology Test for Children With Altered Mental Status

The rate of unintentional ingestion of edible cannabis products in young children is rising rapidly as laws decriminalizing both recreational and medical marijuana in the United States become more widespread.1 Cannabis poisoning in children can lead to a myriad of symptoms, most notably neurologic changes. The abrupt onset and severity of signs and symptoms after ingestion can cause diagnostic uncertainty for practitioners in the emergency department. Here, we present a case series of 5 children, 6 years of age and younger, who initially presented with altered mental status and were ultimately diagnosed with acute δ-9-tetrahydrocannabinol toxicity after cannabis ingestion confirmed by urine toxicology testing. Although urine toxicology testing is not routinely used as a diagnostic tool in pediatrics, the increasing accessibility of edible cannabis products suggests that more widespread urine toxicology testing in children with undifferentiated altered mental status is warranted.

Urine Drug Screens in the Emergency Department: The Best Test May Be No Test at All

The manuscript purpose is to provide a resource for clinicians on the functionality and pitfalls of the rapid urine drug screen for clinical decision making. Many providers remain under-informed about the inherent inaccuracies. The rapid urine drug screen is the first, and often only, step of drug testing. In the majority of emergency departments the urine drug screen is a collection of immunoassays reliant on an interaction between the structure of a particular drug or metabolite and an antibody. Drugs in separate pharmacologic classes often have enough structural similarity to cause false positives. Conversely, drugs within the same pharmacologic class often have different enough structures that they may result in inappropriate negatives. This lack of sensitivity and specificity significantly reduces the test utility, and may cause decision-making confusion. The timing of the drug screen relative to the drug exposure also limits accuracy, as does detection threshold. Confirmatory steps following the initial immunoassay include chromatography and/or mass spectrometry. These are unavailable at many institutions and results rarely return while the patient is in the emergency department. In addition, institutional capabilities vary, even with confirmatory testing. Confirmation accuracy depends on a number of factors, including the extent of the catalog of drugs/metabolites that the facility is calibrated to detect and report. In summary, the standard emergency department urine drug screen is a test with extremely limited clinical utility with multiple properties contributing to poor sensitivity, specificity, and accuracy. The test should be used rarely, if ever, for clinical decision making.

Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 1: epidemiology, methodology and general overview

Acute intoxications account for a significant proportion of the patient population in intensive care units and sedative medications, ethanol, illicit drugs, inhalable poisons and mixed intoxications are the most common causes. The aim of this article is to describe biomarkers for screening and diagnosis of acute intoxications in critically ill patients. For this purpose, a survey of the relevant literature was conducted, and guidelines, case reports, expert assessments, and scientific publications were reviewed. In critical care, it should always be attempted to identify and quantify the poison or toxin with the assistance of enzyme immunoassay (EIA), chromatography, and mass spectrometry techniques and this section is critically appraised in this publication. The principles for anion gap, osmol gap and lactate gap and their usage in intoxications is shown. Basic rules in test methodology and pre-analytics are reviewed. Biomarkers in general are presented in part one and biomarkers for specific intoxications including ethanol, paracetamol, cardiovascular drugs and many others are presented in part two of these publications.

Indications and Interpretation of Common Laboratory Assays in the Emergency Department

Laboratory assays are commonly used to help clinicians more accurately gauge the risk a child has for a certain condition. This article reviews commonly obtained laboratory tests (complete blood cell counts, metabolic panels, blood gases, and urine assays) and discusses the data supporting obtaining these tests and reasons for spuriously positive or negative results.