Clinical Toxicology Downloaded from informahealthcare.com by Flinders University of South Australia on 01/06/15 For personal use only.
CLINICAL TOXICOLOGY 11(5), pp. 573-580 (1977)
Application of the Programmable Calculator in Reporting Emergency Toxicology Data
ROBERT W. SAMUELS, M.A. Toxicologist Gorgas Hospital P. 0. Box 0 Balboa Heights, Canal Zone
In this laboratory, night and weekend coverage in toxicology is provided by a staff of technologists who a r e not routinely assigned to the section and who p e r f o r m a series of screening t e s t s on s p e c i m e n s submitted f o r emergency toxicology a n a l y s e s , in addition to handling s e v e r a l routine a n a l y s e s s u c h as b a r b i t u r a t e and salicylate levels. T h e s e screening t e s t s are designed to provide a maximum amount of information to the physician i n a minimum amount of t i m e and with a minimum amount of specimen consumption. Some of these analyses, such a s those f o r the b a r b i t u r a t e s and salicylates, are easily quantitated and when requested by the physician, t h i s s e r v i c e is provided based upon the r e s u l t s of the initial s c r e e n i n g t e s t s . Ingestions of other d r u g s o r anomalous r e s u l t s are r e f e r r e d to the toxicologist. Blood o r u r i n e alcohol is routinely r e p o r t e d f o r each specimen submitted. Screening t e s t s , as is well known, are subject to i n t e r f e r e n c e by any number of s t r u c t u r a l l y s i m i l a r compounds. However, t h e fact that other compounds i n t e r f e r e in a p a r t i c u l a r t e s t c a n a l s o be used to advantage. A negative screening t e s t f o r b a r b i t u r a t e s , f o r exa m p l e , a l s o rules out the possibility of the p r e s e n c e of significant amounts of diphenylhydantoin, chlorpheniramine, methprylon, diazepam, o r glutethimide.
573 Copyright 0 1978 hy M a r 4 Lkkker. l11c All Rights Reserved. Neither this work nor any part may he reproduced o r transmitted in any form or hy any means. r l e ~ t r i i n ior~ mechanical, including photompying, microfilming. and recording, or hy any information storage and retrieval s)steni. without permission in writing from the puhlisher.
SAMUELS
Clinical Toxicology Downloaded from informahealthcare.com by Flinders University of South Australia on 01/06/15 For personal use only.
574
Due to the infrequency with which some of the technologists receive specimens for emergency toxicology analyses, it became apparent that it was difficult for them to maintain an awareness of the constantly changing patterns in toxicological analyses, especially of which drugs interfere with each other in a particular test. By reporting the results of emergency toxicology analyses using a programmable calculator and calculator plotter, we have overcome these difficulties. In addition to alerting the physician to possible sources of interference in a particular test, the program provides the physician with a listing of currently popular local drugs of abuse that may o r may not be detected by the screening procedure. The emergency toxicology screening tests performed i n this laboratory, a r e listed in Table 1, according to the type of specimen received. The calculator used in this study is a Hewlett-Packard 9810, a key-per-function programmable calculator, equipped with plug-in read-only-memory (ROM) modules for alpha printing and calculator plotter operation. This arrangement permits question and answer conversation between the calculator program and operator with subsequent data print out on the calculator plotter. The program is designed so that the calculator first requests pertinent data such as the patient's name, doctor, date, and the analyst's name; the operator enters this information from the calculator keyboard. The calculator plotter then prints the list of screening tests appropriate to the type of specimen analyzed and the operator enters the result a s either "Positive" o r I'None Detected" a s requested by the calculator printer. The logic employed in printing the report is TABLE 1. Emergency Toxicology Screening Tests Specimen
Screening test
Reference
Blood
Alcohol
Sunshine [l]
Barbiturate
Helman [2]
Salicyla te
Natleson [3]
Acetone
Dipstick (LABSTIX)
Alcohol
Sunshine [l]
Urine
Alkaloid
Mayer' s Reagent
Barbiturate
Helman [2]
Phenothiazine
Forest and Forest [4, 51
Salicylate
Natleson [3]
-
PROGRAMMABLE EMERGENCY TOXICOLOGY
57 5
PRELIMINARY DATA
Clinical Toxicology Downloaded from informahealthcare.com by Flinders University of South Australia on 01/06/15 For personal use only.
PATIENT, DOCTOR, DATE, ANALYST
(PLCTYER)
+
ALL TESTS (CALCULATOR)
A URINE DRUG SCREEN
ONE OR MORE TESTS POSITIVE (CALCULATOR)
1
POSSIBLE INTERFERING COMPOUNDS (PLOTTER)
1 FOR THOSE POSITIVE TESTS SUBJECT TO QUANTITATION
LEVEL REQUESTED? (CALCULATOR)
I
L
PRINT LEVEL (PLCTTER)
TEST COMMENTS (PLOTTER) C O M M O N LOCAL DRUG (PLOTTER)
FIG. 1. Schematic of data input and calculator/plotter output. illustrated schematically in Fig. 1 for a urine drug screen. A si m i l ar, but s h o r te r sequence is used to report results from blood specimens, since fewer te s t s are performed on blood. If no drugs a r e detected in any of the screening t est s the plotter prints "Urine ( o r Blood) Drug Screen Negative" and then proceeds to
SAMUELS
57 6 EMERGENCY TOXICOLOGY SCREEN C URINE 3
PATIENT Clinical Toxicology Downloaded from informahealthcare.com by Flinders University of South Australia on 01/06/15 For personal use only.
DOCTOR ANALYST
. .
DRTE
.
.
SCREWING TEST
RESULT
URINE DRUG SCREEN NEGRTIVE
CURRENT LOCRL DRUGS OF ABUSE t 2 / 6 / 7 7 3 RRTRNE ICRPTR~DN I VRLIUM
R. W. SAMUEL5
1
2/6/77
FIG. 2. Negative urine drug screen report.
list the currently popular local drugs of abuse as shoirn in Fig. 2. This listing is updated monthly and provides the physician with possible alternatives to consider. If a "Positive" result is entered, the plotter then lists compounds that have been demonstrated to interfere in that particular test. For example, the physician is reminded that high levels of salicylates may interfere i n the phenothiazine screen as shown in Fig. 3. These preprogrammed responses a r e listed in Table 2 for the urine emergency toxicology screen. The plotter next lists the three tests for which a quantitative o r semi-quantitative analysis i s available i f any of these three tests is positive in the screening test results. As noted before, the alcohol range is routinely determined on each specimen, whether blood o r urine, and these results a r e entered from the calculator keyboard. When a barbiturate screen is positive, the physician has the choice
PROGRAMMABLE EMERGENCY TOXICOLOGY
Clinical Toxicology Downloaded from informahealthcare.com by Flinders University of South Australia on 01/06/15 For personal use only.
EMERGENCY TOXICOLOGY SCREEN
PRTIENT
.
DOCTUR
.
RNALYST
577
L URINE 3 DRTE
.
5CREENING TE5T
RE5ULT
P055MLE INTERFERING COMPOUND5
PHENOTHI Z NE SCREEN L HIGH LEVELS I SRLlCfLR%!i
CURRENT LOCRL DRUG5 OF RWSE C 2/6/77 RRTRNE ICRPTRGON
I
1
VRLIUM R. W. 5RMUELS
I
2/6/77
FIG. 3. Positive phenothiazine drug s c r e e n report. of requesting o r not requesting a barbiturate level. If the physician chooses not to have a barbiturate level done, this is noted on the laboratory report by a pre-programmed response. If the physician opts for a barbiturate level, the analytical result is printed along with the pre-programmed comment that the ultraviolet spectrophotometr ic procedure employed in this laboratory does not identify the barbiturate type.
SAMUELS
57 8 EMERGENCY TOXICOLOGY SCREEN CBLPDDI
. DOCTOR . RNRLY5T .
Clinical Toxicology Downloaded from informahealthcare.com by Flinders University of South Australia on 01/06/15 For personal use only.
PRTIENT
5CREE"G
DRTE
TE5T
RESULT
ELOUD RLCUHUL RRNGE :
80-178 MWDL
BRRBITURRTE LEVEL
=
.
0.2s MG/DL
SPECTRRL RNRLY5E DOE5 NOT IDENTIFY RFHBITURRTE TYPE
SRLICYLRTE LEVEL
15 MWDL
I
CURRENT LOCAL DRUGS OF RBU5E C RRTRNE
/
CRPTRGON
I
2/ 7/77 3
VRLlLlM R. W. SRMUELS
/
2/7/77
FIG. 4. Positive alcohol, barbiturate, and salicylate drug screen
report.
PROGRAMMABLE EMERGENCY TOXICOLOGY
57 9
Clinical Toxicology Downloaded from informahealthcare.com by Flinders University of South Australia on 01/06/15 For personal use only.
TABLE 2. Pre-Programmed Calculator Responses T es t
Response
Acetone s cr een
Other ketones
Alcohol s cr een
Methanol, acetone, etc. but patient is clinically different
Alkaloid s cr een
None reported
Barbiturate s c r een
Dilantin, chlorpheniramine, methyprylon, Valium, Doriden
Phenothiazine s c r een
Salicylates (high levels)
Salicylate s c r een
Thiocyanate (appreciable amounts)
If the salicylate screen is positive, the physician again has the choice of requesting o r not requesting a salicylate level. As in the c as e of the barbiturates, the appropriate result is entered o r the comment is printed that a salicylate level was not requested. Figure 4 illustrates a case where all three screening tests subject to quantitation were positive and the hypothetical results that might have been obtained. A s mentioned previously, the calculator plotter finally prints the l i s t of currently popular local drugs of abuse. SUMMARY The use of a programmable calculator in reporting the results of emergency toxicology analyses by personnel who do not routinely perform such analyses has eliminated the problems previously encountered due to unfamiliarity with a particular test o r tests. The program that is used a l e r t s the physician to those drugs that could possibly interfere in the screening tests used for emergency toxicology analyses and, in addition, provides him o r h e r with an updated listing of popular s t r e e t and recreational drugs and drugs of abuse in this area in the event that one of these is not detectable in the screening procedure. REFERENCES
[ 11 I. Sunshine, "Alcohol in Biological Materials,'' in Standard
Methods of Clinical Chemistry, Vol. 3 (D. S e l i g s o m Academic, New York, 1961, pp. 8-13.
Clinical Toxicology Downloaded from informahealthcare.com by Flinders University of South Australia on 01/06/15 For personal use only.
580
SAMUELS
[2] E. Z. Helman, Emergency screening of urine, plasma, o r gastric contents for barbiturates, Clin. Chem., 16, 797 (1970). [3] S. Natleson, Microtechniques of Clinical Chemistry, 2nd ed., Charles C Thomas, Springfield, 1961, pp. 372-374. [4] I. S. Forest and F. M. Forest, Urine color test f o r the detection of phenothiazine compounds, Clin. Chem., 6, 11 (1960). [5] F. M. Forest and I. S. Forest, A rapid urinaryTest for chlorpromazine, promazine, and pacatal: a supplementary report, Am. J. Psychiatry., 113,931 (1957).
CLINICAL TOXICOLOGY 11(5), pp. 573-580 (1977)
Application of the Programmable Calculator in Reporting Emergency Toxicology Data
ROBERT W. SAMUELS, M.A. Toxicologist Gorgas Hospital P. 0. Box 0 Balboa Heights, Canal Zone
In this laboratory, night and weekend coverage in toxicology is provided by a staff of technologists who a r e not routinely assigned to the section and who p e r f o r m a series of screening t e s t s on s p e c i m e n s submitted f o r emergency toxicology a n a l y s e s , in addition to handling s e v e r a l routine a n a l y s e s s u c h as b a r b i t u r a t e and salicylate levels. T h e s e screening t e s t s are designed to provide a maximum amount of information to the physician i n a minimum amount of t i m e and with a minimum amount of specimen consumption. Some of these analyses, such a s those f o r the b a r b i t u r a t e s and salicylates, are easily quantitated and when requested by the physician, t h i s s e r v i c e is provided based upon the r e s u l t s of the initial s c r e e n i n g t e s t s . Ingestions of other d r u g s o r anomalous r e s u l t s are r e f e r r e d to the toxicologist. Blood o r u r i n e alcohol is routinely r e p o r t e d f o r each specimen submitted. Screening t e s t s , as is well known, are subject to i n t e r f e r e n c e by any number of s t r u c t u r a l l y s i m i l a r compounds. However, t h e fact that other compounds i n t e r f e r e in a p a r t i c u l a r t e s t c a n a l s o be used to advantage. A negative screening t e s t f o r b a r b i t u r a t e s , f o r exa m p l e , a l s o rules out the possibility of the p r e s e n c e of significant amounts of diphenylhydantoin, chlorpheniramine, methprylon, diazepam, o r glutethimide.
573 Copyright 0 1978 hy M a r 4 Lkkker. l11c All Rights Reserved. Neither this work nor any part may he reproduced o r transmitted in any form or hy any means. r l e ~ t r i i n ior~ mechanical, including photompying, microfilming. and recording, or hy any information storage and retrieval s)steni. without permission in writing from the puhlisher.
SAMUELS
Clinical Toxicology Downloaded from informahealthcare.com by Flinders University of South Australia on 01/06/15 For personal use only.
574
Due to the infrequency with which some of the technologists receive specimens for emergency toxicology analyses, it became apparent that it was difficult for them to maintain an awareness of the constantly changing patterns in toxicological analyses, especially of which drugs interfere with each other in a particular test. By reporting the results of emergency toxicology analyses using a programmable calculator and calculator plotter, we have overcome these difficulties. In addition to alerting the physician to possible sources of interference in a particular test, the program provides the physician with a listing of currently popular local drugs of abuse that may o r may not be detected by the screening procedure. The emergency toxicology screening tests performed i n this laboratory, a r e listed in Table 1, according to the type of specimen received. The calculator used in this study is a Hewlett-Packard 9810, a key-per-function programmable calculator, equipped with plug-in read-only-memory (ROM) modules for alpha printing and calculator plotter operation. This arrangement permits question and answer conversation between the calculator program and operator with subsequent data print out on the calculator plotter. The program is designed so that the calculator first requests pertinent data such as the patient's name, doctor, date, and the analyst's name; the operator enters this information from the calculator keyboard. The calculator plotter then prints the list of screening tests appropriate to the type of specimen analyzed and the operator enters the result a s either "Positive" o r I'None Detected" a s requested by the calculator printer. The logic employed in printing the report is TABLE 1. Emergency Toxicology Screening Tests Specimen
Screening test
Reference
Blood
Alcohol
Sunshine [l]
Barbiturate
Helman [2]
Salicyla te
Natleson [3]
Acetone
Dipstick (LABSTIX)
Alcohol
Sunshine [l]
Urine
Alkaloid
Mayer' s Reagent
Barbiturate
Helman [2]
Phenothiazine
Forest and Forest [4, 51
Salicylate
Natleson [3]
-
PROGRAMMABLE EMERGENCY TOXICOLOGY
57 5
PRELIMINARY DATA
Clinical Toxicology Downloaded from informahealthcare.com by Flinders University of South Australia on 01/06/15 For personal use only.
PATIENT, DOCTOR, DATE, ANALYST
(PLCTYER)
+
ALL TESTS (CALCULATOR)
A URINE DRUG SCREEN
ONE OR MORE TESTS POSITIVE (CALCULATOR)
1
POSSIBLE INTERFERING COMPOUNDS (PLOTTER)
1 FOR THOSE POSITIVE TESTS SUBJECT TO QUANTITATION
LEVEL REQUESTED? (CALCULATOR)
I
L
PRINT LEVEL (PLCTTER)
TEST COMMENTS (PLOTTER) C O M M O N LOCAL DRUG (PLOTTER)
FIG. 1. Schematic of data input and calculator/plotter output. illustrated schematically in Fig. 1 for a urine drug screen. A si m i l ar, but s h o r te r sequence is used to report results from blood specimens, since fewer te s t s are performed on blood. If no drugs a r e detected in any of the screening t est s the plotter prints "Urine ( o r Blood) Drug Screen Negative" and then proceeds to
SAMUELS
57 6 EMERGENCY TOXICOLOGY SCREEN C URINE 3
PATIENT Clinical Toxicology Downloaded from informahealthcare.com by Flinders University of South Australia on 01/06/15 For personal use only.
DOCTOR ANALYST
. .
DRTE
.
.
SCREWING TEST
RESULT
URINE DRUG SCREEN NEGRTIVE
CURRENT LOCRL DRUGS OF ABUSE t 2 / 6 / 7 7 3 RRTRNE ICRPTR~DN I VRLIUM
R. W. SAMUEL5
1
2/6/77
FIG. 2. Negative urine drug screen report.
list the currently popular local drugs of abuse as shoirn in Fig. 2. This listing is updated monthly and provides the physician with possible alternatives to consider. If a "Positive" result is entered, the plotter then lists compounds that have been demonstrated to interfere in that particular test. For example, the physician is reminded that high levels of salicylates may interfere i n the phenothiazine screen as shown in Fig. 3. These preprogrammed responses a r e listed in Table 2 for the urine emergency toxicology screen. The plotter next lists the three tests for which a quantitative o r semi-quantitative analysis i s available i f any of these three tests is positive in the screening test results. As noted before, the alcohol range is routinely determined on each specimen, whether blood o r urine, and these results a r e entered from the calculator keyboard. When a barbiturate screen is positive, the physician has the choice
PROGRAMMABLE EMERGENCY TOXICOLOGY
Clinical Toxicology Downloaded from informahealthcare.com by Flinders University of South Australia on 01/06/15 For personal use only.
EMERGENCY TOXICOLOGY SCREEN
PRTIENT
.
DOCTUR
.
RNALYST
577
L URINE 3 DRTE
.
5CREENING TE5T
RE5ULT
P055MLE INTERFERING COMPOUND5
PHENOTHI Z NE SCREEN L HIGH LEVELS I SRLlCfLR%!i
CURRENT LOCRL DRUG5 OF RWSE C 2/6/77 RRTRNE ICRPTRGON
I
1
VRLIUM R. W. 5RMUELS
I
2/6/77
FIG. 3. Positive phenothiazine drug s c r e e n report. of requesting o r not requesting a barbiturate level. If the physician chooses not to have a barbiturate level done, this is noted on the laboratory report by a pre-programmed response. If the physician opts for a barbiturate level, the analytical result is printed along with the pre-programmed comment that the ultraviolet spectrophotometr ic procedure employed in this laboratory does not identify the barbiturate type.
SAMUELS
57 8 EMERGENCY TOXICOLOGY SCREEN CBLPDDI
. DOCTOR . RNRLY5T .
Clinical Toxicology Downloaded from informahealthcare.com by Flinders University of South Australia on 01/06/15 For personal use only.
PRTIENT
5CREE"G
DRTE
TE5T
RESULT
ELOUD RLCUHUL RRNGE :
80-178 MWDL
BRRBITURRTE LEVEL
=
.
0.2s MG/DL
SPECTRRL RNRLY5E DOE5 NOT IDENTIFY RFHBITURRTE TYPE
SRLICYLRTE LEVEL
15 MWDL
I
CURRENT LOCAL DRUGS OF RBU5E C RRTRNE
/
CRPTRGON
I
2/ 7/77 3
VRLlLlM R. W. SRMUELS
/
2/7/77
FIG. 4. Positive alcohol, barbiturate, and salicylate drug screen
report.
PROGRAMMABLE EMERGENCY TOXICOLOGY
57 9
Clinical Toxicology Downloaded from informahealthcare.com by Flinders University of South Australia on 01/06/15 For personal use only.
TABLE 2. Pre-Programmed Calculator Responses T es t
Response
Acetone s cr een
Other ketones
Alcohol s cr een
Methanol, acetone, etc. but patient is clinically different
Alkaloid s cr een
None reported
Barbiturate s c r een
Dilantin, chlorpheniramine, methyprylon, Valium, Doriden
Phenothiazine s c r een
Salicylates (high levels)
Salicylate s c r een
Thiocyanate (appreciable amounts)
If the salicylate screen is positive, the physician again has the choice of requesting o r not requesting a salicylate level. As in the c as e of the barbiturates, the appropriate result is entered o r the comment is printed that a salicylate level was not requested. Figure 4 illustrates a case where all three screening tests subject to quantitation were positive and the hypothetical results that might have been obtained. A s mentioned previously, the calculator plotter finally prints the l i s t of currently popular local drugs of abuse. SUMMARY The use of a programmable calculator in reporting the results of emergency toxicology analyses by personnel who do not routinely perform such analyses has eliminated the problems previously encountered due to unfamiliarity with a particular test o r tests. The program that is used a l e r t s the physician to those drugs that could possibly interfere in the screening tests used for emergency toxicology analyses and, in addition, provides him o r h e r with an updated listing of popular s t r e e t and recreational drugs and drugs of abuse in this area in the event that one of these is not detectable in the screening procedure. REFERENCES
[ 11 I. Sunshine, "Alcohol in Biological Materials,'' in Standard
Methods of Clinical Chemistry, Vol. 3 (D. S e l i g s o m Academic, New York, 1961, pp. 8-13.
Clinical Toxicology Downloaded from informahealthcare.com by Flinders University of South Australia on 01/06/15 For personal use only.
580
SAMUELS
[2] E. Z. Helman, Emergency screening of urine, plasma, o r gastric contents for barbiturates, Clin. Chem., 16, 797 (1970). [3] S. Natleson, Microtechniques of Clinical Chemistry, 2nd ed., Charles C Thomas, Springfield, 1961, pp. 372-374. [4] I. S. Forest and F. M. Forest, Urine color test f o r the detection of phenothiazine compounds, Clin. Chem., 6, 11 (1960). [5] F. M. Forest and I. S. Forest, A rapid urinaryTest for chlorpromazine, promazine, and pacatal: a supplementary report, Am. J. Psychiatry., 113,931 (1957).
