CORRESPONDENCE
N o m e n t i o n is m a d e of calibration of either t h e r m o m e ter. N o m e n t i o n of the m o d e of the First T e m p ® during t e m p e r a t u r e m e a s u r e m e n t is r e p o r t e d . B e c a u s e F i r s t T e m p ® reports t e m p e r a t u r e values as "core," "rectal," or "oral" equivalents, considerable variation in t e m p e r a t u r e results m a y have resulted in the relatively poor correlation observed. C o m b i n i n g the r e s u l t s of oral and r e c t a l t e m p e r a t u r e to derive a single regression line, w i t h o u t correcting for differences b e t w e e n oral and rectal temperature, is inappropriate. Finally, no m e n t i o n is m a d e of excluding p a t i e n t s w i t h factors k n o w n to spuriously influence oral t e m p e r a t u r e m e a s u r e m e n t , such as t a c h y p n e a or h o t and cold liquid ingestion.6, 7 U n l e s s clarification of these issues is possible, I recomm e n d caution in accepting the conclusions of this study. Thomas E Terndrup, M D Departments of Critical Care & Emergency Medicine and Pediatrics S U N Y Health Science Center Syracuse, N e w York
l, Nichols GA, Fielding JJ, McKevitt RK, et al: Taking oral temperatures of febrile patients. Nurs Res 1969;18:448-450. 2. Nichols GA, Kucha DH: Oral measurements. Am J Nuts 1972;72: 1091-1093. 3. Nichols GA, Kulvi RL, Life HR, et al: Measuring oral and rectal temperatures of febrile children. Nurs Res 1972;21:261-264. 4. Nichols GA, Ruskin MMt Glor BAK, et al: Oral, axillary, and rectal temperature determinations and relationships. Nurs Res 1966~15:307-310. 5. Baker NC, Bidwell-Cerone S, Gaze N, et al: The effect of type of thermometer and length of time inserted on oral temperature measurements of afebrile subjects. Nurs Res 1984;33:109-111.
6. Tanberg D, Sklar D: Effect of tachypnea on the estimation of body temperature by an oral thermometer. N ErzglJ Med 1983;308-945-946. 7. Temdrup TE, Allegra JR, Kealy JA: A comparison of oral, rectal and tympanic membrane-derivedtemperature changes after ingestion of liquids and smoking. Am ] Emerg Med 1989;7:150-154.
in Reply: I t h a n k Dr Terndrup for his c o m m e n t s and questions. The glass-mercury t h e r m o m e t e r m e a s u r e m e n t s were obtained by holding the t h e r m o m e t e r in the orifice u n t i l stabilization of the reading - a process u s u a l l y t a k i n g app r o x i m a t e l y three to five m i n u t e s (no a t t e m p t s were m a d e to record the exact duration of this procedure). The physician obtaining the t y m p a n i c m e m b r a n e temperature was blinded to the results of oral and rectal meas u r e m e n t s that were obtained b y the nursing personnel. The t y m p a n i c m e m b r a n e t h e r m o m e t e r was always used in the appropriate m o d e - ie, if rectal t e m p e r a t u r e was normal, the device was in the rectal mode, etc. T h e results of oral and rectal t e m p e r a t u r e s were combined because of the relatively s m a l l n u m b e r of s t u d y subjects in each group and the low l i k e l i h o o d of the n e w device r e p l a c i n g the m e a s u r e m e n t of rectal and oral t e m peratures only. Finally, we have a policy of n o t allowing our p a t i e n t s to ingest liquids prior to being evaluated, and tachypneic patients do not have oral t e m p e r a t u r e m e a s u r e m e n t s . Simon P R o s , MD Pediatric Emergency Medicine Loyola University Stritch School of Medicine Maywood, Illinois
Saliva Teststrips for Alcohol Testing To the Editor: We read w i t h i n t e r e s t the a r t i c l e by S c h w a r t z et al, "Evaluation of C o l o r i m e t r i c D i p s t i c k Test to D e t e c t Alcohol in Saliva: A Pilot Study" [September 1989;18: 1001-1003]. U s i n g a n o t h e r c o m m e r c i a l l y available salivary alcohol dipstick that was referred to in their article, the AlcoScan ~ (Lifescan, Inc), we also found c o l o r i m e t r i c s c r e e n i n g a useful test for a l c o h o l i n t o x i c a t i o n in the e m e r g e n c y department. The AlcoScan ~ saliva teststrip for salivary alcohol also uses a color change from no color, to light blue, to dark purple corresponding w i t h semiquantitative i n c r e m e n t s of 0, 0.01 g%, 0.05 g%, and 0.1 g% b l o o d a l c o h o l l e v e l s . We w e r e o r i g i n a l l y i n t e r e s t e d in using the teststrip to screen psychiatric patients requiring medical clearance w i t h a blood alcohol level of less than 0.1 g%, but our s t u d y group also included patients w i t h t r a u m a and m e d i c a l l y related conditions. F r o m January to M a r c h 1988, 38 patients were tested a n d t h e r e s u l t s of t h e t e s t s t r i p c o m p a r e d to a s i m u l taneous blood alcohol run on the hospital T D x REA Eth186/342
anol A s s a y (Abbot Laboratories). O u r results were n o t reported due to the s t a t i s t i c a l l y s m a l l sample size and subsequent lack of supplies by the manufacturer. We found that the teststrip (AS) was very good at separating patients w i t h a blood alcohol of m o r e than 0.1 g% from those w i t h levels less than 0.05 g%. Blood alcohol levels ranged from 0 to 0.43 g%. Seven s p e c i m e n s were 0, all of w h i c h correlated w i t h the teststrip, except one that was read at 0.01 g% by AS. All 11 samples less t h a n 0.05 g% blood alcohol were confirmed by the teststrip to be in the same range; all 26 specimens found to be greater than or equal to 0.1 g% by blood alcohol were confirmed by the teststrip, except for three samples that were lower as a result of saliva sampling error (no saliva or d i l u t i o n from water ingested prior to sampling). One test s a m p l e correlated poorly for an u n k n o w n reason - BA 0.32, AS m o r e t h a n 0.05 g%. Therefore, as a screening m o d a l i t y the teststrip was excellent at separating p a t i e n t s w i t h BA of 0.1 g% or m o r e
Annals of Emergency Medicine
19:3 March 1990
(96% accuracy). In the case of head injury or altered mental status n o t due to alcohol, the strip was helpful if less t h a n or equal to 0.05 g%. This teststrip is not FDA approved for medically related use and m a y have explained the reluctance on the part of the m a n u f a c t u r e r to complete the study. As a result of this, we are i n the process of evaluating the use of another modality for alcohol screening i n the e m e r g e n c y d e p a r t m e n t , a passive, h a n d - h e l d breath alcohol u n i t called the Alco-Sensor III device (Intoximeters, Inc). 1 We anticipate that this m e t h o d will be more precise, less invasive, and simpler to use t h a n the
19:3 March 1990
current saliva teststrip m e t h o d s now available.
Alan Buchwald, MD, FACEP Jerry Smith, MS Emergency Department Santa Clara Valley Medical Center San Jose, California 1. GerberichSG, et al: Analysesof the relationshipbetween blood alcohol and nasal breath alcohol concentrations: Implications for assessment of trauma cases. J Trauma 1989;29:338-343.
Annals of Emergency Medicine
343/187
N o m e n t i o n is m a d e of calibration of either t h e r m o m e ter. N o m e n t i o n of the m o d e of the First T e m p ® during t e m p e r a t u r e m e a s u r e m e n t is r e p o r t e d . B e c a u s e F i r s t T e m p ® reports t e m p e r a t u r e values as "core," "rectal," or "oral" equivalents, considerable variation in t e m p e r a t u r e results m a y have resulted in the relatively poor correlation observed. C o m b i n i n g the r e s u l t s of oral and r e c t a l t e m p e r a t u r e to derive a single regression line, w i t h o u t correcting for differences b e t w e e n oral and rectal temperature, is inappropriate. Finally, no m e n t i o n is m a d e of excluding p a t i e n t s w i t h factors k n o w n to spuriously influence oral t e m p e r a t u r e m e a s u r e m e n t , such as t a c h y p n e a or h o t and cold liquid ingestion.6, 7 U n l e s s clarification of these issues is possible, I recomm e n d caution in accepting the conclusions of this study. Thomas E Terndrup, M D Departments of Critical Care & Emergency Medicine and Pediatrics S U N Y Health Science Center Syracuse, N e w York
l, Nichols GA, Fielding JJ, McKevitt RK, et al: Taking oral temperatures of febrile patients. Nurs Res 1969;18:448-450. 2. Nichols GA, Kucha DH: Oral measurements. Am J Nuts 1972;72: 1091-1093. 3. Nichols GA, Kulvi RL, Life HR, et al: Measuring oral and rectal temperatures of febrile children. Nurs Res 1972;21:261-264. 4. Nichols GA, Ruskin MMt Glor BAK, et al: Oral, axillary, and rectal temperature determinations and relationships. Nurs Res 1966~15:307-310. 5. Baker NC, Bidwell-Cerone S, Gaze N, et al: The effect of type of thermometer and length of time inserted on oral temperature measurements of afebrile subjects. Nurs Res 1984;33:109-111.
6. Tanberg D, Sklar D: Effect of tachypnea on the estimation of body temperature by an oral thermometer. N ErzglJ Med 1983;308-945-946. 7. Temdrup TE, Allegra JR, Kealy JA: A comparison of oral, rectal and tympanic membrane-derivedtemperature changes after ingestion of liquids and smoking. Am ] Emerg Med 1989;7:150-154.
in Reply: I t h a n k Dr Terndrup for his c o m m e n t s and questions. The glass-mercury t h e r m o m e t e r m e a s u r e m e n t s were obtained by holding the t h e r m o m e t e r in the orifice u n t i l stabilization of the reading - a process u s u a l l y t a k i n g app r o x i m a t e l y three to five m i n u t e s (no a t t e m p t s were m a d e to record the exact duration of this procedure). The physician obtaining the t y m p a n i c m e m b r a n e temperature was blinded to the results of oral and rectal meas u r e m e n t s that were obtained b y the nursing personnel. The t y m p a n i c m e m b r a n e t h e r m o m e t e r was always used in the appropriate m o d e - ie, if rectal t e m p e r a t u r e was normal, the device was in the rectal mode, etc. T h e results of oral and rectal t e m p e r a t u r e s were combined because of the relatively s m a l l n u m b e r of s t u d y subjects in each group and the low l i k e l i h o o d of the n e w device r e p l a c i n g the m e a s u r e m e n t of rectal and oral t e m peratures only. Finally, we have a policy of n o t allowing our p a t i e n t s to ingest liquids prior to being evaluated, and tachypneic patients do not have oral t e m p e r a t u r e m e a s u r e m e n t s . Simon P R o s , MD Pediatric Emergency Medicine Loyola University Stritch School of Medicine Maywood, Illinois
Saliva Teststrips for Alcohol Testing To the Editor: We read w i t h i n t e r e s t the a r t i c l e by S c h w a r t z et al, "Evaluation of C o l o r i m e t r i c D i p s t i c k Test to D e t e c t Alcohol in Saliva: A Pilot Study" [September 1989;18: 1001-1003]. U s i n g a n o t h e r c o m m e r c i a l l y available salivary alcohol dipstick that was referred to in their article, the AlcoScan ~ (Lifescan, Inc), we also found c o l o r i m e t r i c s c r e e n i n g a useful test for a l c o h o l i n t o x i c a t i o n in the e m e r g e n c y department. The AlcoScan ~ saliva teststrip for salivary alcohol also uses a color change from no color, to light blue, to dark purple corresponding w i t h semiquantitative i n c r e m e n t s of 0, 0.01 g%, 0.05 g%, and 0.1 g% b l o o d a l c o h o l l e v e l s . We w e r e o r i g i n a l l y i n t e r e s t e d in using the teststrip to screen psychiatric patients requiring medical clearance w i t h a blood alcohol level of less than 0.1 g%, but our s t u d y group also included patients w i t h t r a u m a and m e d i c a l l y related conditions. F r o m January to M a r c h 1988, 38 patients were tested a n d t h e r e s u l t s of t h e t e s t s t r i p c o m p a r e d to a s i m u l taneous blood alcohol run on the hospital T D x REA Eth186/342
anol A s s a y (Abbot Laboratories). O u r results were n o t reported due to the s t a t i s t i c a l l y s m a l l sample size and subsequent lack of supplies by the manufacturer. We found that the teststrip (AS) was very good at separating patients w i t h a blood alcohol of m o r e than 0.1 g% from those w i t h levels less than 0.05 g%. Blood alcohol levels ranged from 0 to 0.43 g%. Seven s p e c i m e n s were 0, all of w h i c h correlated w i t h the teststrip, except one that was read at 0.01 g% by AS. All 11 samples less t h a n 0.05 g% blood alcohol were confirmed by the teststrip to be in the same range; all 26 specimens found to be greater than or equal to 0.1 g% by blood alcohol were confirmed by the teststrip, except for three samples that were lower as a result of saliva sampling error (no saliva or d i l u t i o n from water ingested prior to sampling). One test s a m p l e correlated poorly for an u n k n o w n reason - BA 0.32, AS m o r e t h a n 0.05 g%. Therefore, as a screening m o d a l i t y the teststrip was excellent at separating p a t i e n t s w i t h BA of 0.1 g% or m o r e
Annals of Emergency Medicine
19:3 March 1990
(96% accuracy). In the case of head injury or altered mental status n o t due to alcohol, the strip was helpful if less t h a n or equal to 0.05 g%. This teststrip is not FDA approved for medically related use and m a y have explained the reluctance on the part of the m a n u f a c t u r e r to complete the study. As a result of this, we are i n the process of evaluating the use of another modality for alcohol screening i n the e m e r g e n c y d e p a r t m e n t , a passive, h a n d - h e l d breath alcohol u n i t called the Alco-Sensor III device (Intoximeters, Inc). 1 We anticipate that this m e t h o d will be more precise, less invasive, and simpler to use t h a n the
19:3 March 1990
current saliva teststrip m e t h o d s now available.
Alan Buchwald, MD, FACEP Jerry Smith, MS Emergency Department Santa Clara Valley Medical Center San Jose, California 1. GerberichSG, et al: Analysesof the relationshipbetween blood alcohol and nasal breath alcohol concentrations: Implications for assessment of trauma cases. J Trauma 1989;29:338-343.
Annals of Emergency Medicine
343/187
