ORIGINAL CONTRIBUTION toxicology screening, trauma
Toxicology Screening of the Trauma Patient: A Changing Profile Study objectives: To determine the current ingestants found in the multiply injured trauma patient and to determine if this select group of ingesrants affected the resuscitation, evaluation, or convalescent management of these Patients. Design: A one-year retrospective analysis was performed on all patients who were admitted to an urban trauma center with a discharge diagnosis of multiple trauma and who received a comprehensive toxicology screening test. Main results: One hundred twenty-seven of the 177 patients (72%) who fulfilled the criteria had positive toxicology screens. Ethyl alcohol was the only drug present in 26 of thes e patients (20%); 57 (45%) were positive for drugs other than ethyl alcohol. A combination of ethyl alcohol and at least one other drug was quantified in 44 patients (35%)i The most often encountered substances were ethyl alcohol (55%), marijuana (24%), and cocaine (21%). Twelve drug screens (9%) demonstrated pharmaceuticals (eg, acetylsalicylic acid, acetaminophen, or cyclic antidepressants) that may require specific antidotal treatment. Conclusion: The ingestant profile found in this subgroup of trauma patients differed from those of previous studies. Although a select group of these ingestants require s specific treatment or affects the physical assessment of the patient, none of these trauma patients received more than supportive care. [Clark RF, Harchelroad F: Toxicology screening of the trauma patient: A changing profile. Ann Emerg Med February 1991;20:
151-153.1
Richard F Clark, MD* Phoenix, Arizona Fred Harchelroad, MDt Pittsburgh, Pennsylvania From the Department of Medical Toxicology, Good Samaritan Medical Center, Phoenix, Arizona;* and the Division of Emergency Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania.t Received for publication September 18, 1989. Revision received May 9, 1990. Accepted for publication August 1, 1990. Presented at the 1989 AAPCC/AACT/ ABMT/CAPCC Scientific Assembly in Atlanta, Georgia, October 1989. Address for reprints: Fred Harchelroad, MD, Division of Emergency Medicine, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, Pennsylvania 15212.
INTRODUCTION Comprehensive toxicology screens are used in many emergency deparb ments and trauma services to aid in the differential diagnosis of the patient with mental status changes. Although several studies 1-7 have determined the incongruence between history taking and physical examination in the emergency care setting and the occurrence of actual drugs ingested, other studies8, 9 have noted that routine comprehensive toxicology Screening may not be cost efficient in the trauma patient. Although it may be impossible to determine by physical examination alone whether the mental status and vital sign abnormalities seen in the trauma patient are secondary to head injury, hypovolemic or cardiogenic shock, substance abuse, or a combination, most patients will have multiple diagnostic and therapeutic procedures performed before completion of comprehensive toxicology screens. To question the usefulness of these screens and to note any changing trends from earlier studies, the results obtained from comprehensive toxicology screens of patients admitted to a large urban trauma service were reviewed.
MATERIALS A N D M E T H O D S Patients admitted to the trauma service with any type of altered mental status may, at the discretion of the attending physician, have a screen obtained. Several of the attending physicians obtained a screen on most of their patients; other physicians never obtained a screen on their patients. Because of the random nature of physician care, we believed that no selec-
20:2 February 1991
Annals of Emergency Medicine
151/63
TOXICOLOGY SCREEN Clark & Harchelroad
TABLE 1. Substances found in addition to ethyl alcohol in 44 patients Substance*
Cocaine Marijuana (THC) Benzodiazepines Opiates Quinine Antihistamine Cyclic antidepressant Phenobarbital Salicylate Phenylpropanolamine Meprobamate Phenothiazine Nonsteroidalanti-inflammatorydrugs Total
No. of Patients
16 14 6 4 3
2 2 2 1 1 1 1 1 54t
% 34.4
31.8 13,6 9.1 6.8 4.5 4.5 4.5 2.3 2.3 2.3 2.3 2.3
*Listed nonspedPcallyby categor~ tSeveral patients had more than one substancepresent.
tion bias existed for the entrance of these patients into the study. Comprehensive toxicology screens were not obtained on patients unless they had altered mental status. This retrospective review was performed on patients a d m i t t e d b e t w e e n April 1, 1988, and March 31, 1989. Both blood and urine specimens were obtained on these patients and evaluated as a comprehensive screen. The presence of a drug was confirmed by gas chromatography or mass spectrometry. T u r n a r o u n d time from w h e n the samples were obtained to the receipt of the final results averaged four hours. C o m p r e h e n s i v e toxicology screen results are reported as both qualitative (urine) and quantitative (blood), with the exception of marijuana, which was reported only qualitatively as THC. Inclusion criteria for the present study were a diagnosis of multiple trauma determined in the ED before admission to the trauma service, altered m e n t a l status d o c u m e n t e d since the time of the accident, and both blood and urine specimens obtained for toxicologic analysis. TO obtain a final discharge diagnosis of "multiple trauma," the patient must have had injuries to two or more organ systems. Because the physical finding of "altered mental status" is not listed on the c o m p u t e r i z e d trauma registry, it is unknown how many patients with altered mental 64/152
TABLE 2. Substances found without the presence of ethyl alcohol in 57 patients Substance*
Marijuana(THC) Opiates Cocaine Benzodiazepines Salicylate Cyclic antidepressant Phenyt°in Antihistamine Quinine Amphetamine Acetaminophen Phenylpropanolamine Meprobamate Carbamazepine Tetrahydrozoline Acetone Total
No. of Patients
17 14 11 10 5 4 3 3 3 3 3 2 1 1 1 1 82t
TABLE 3. Substances found in 127 trauma patients Substance*
%
29.8 24.5 19,2 17.5 8.7 7.0 5.3 5.3 5.3 5.3 5.3 3.5 1.8 1.8 1.8 1.8
*Usted nonspeciflcally by category. tSeveral patienls had more than one substancepresent
status were not i n c l u d e d in the study.
No. of Patients
Ethyl alcohol 70 Marijuana (THC) 31 Cocaine 27 Opiates = 18 Benzodiazepines 16 Cyclic antidepressant 6 Salicylate 6 Quinine 6 Phenytoin 5 Antihistamine 5 Phenylpropanolamine 3 Amphetamine 3 Acetaminophen 3 Meprobamate 2 Phenobarbital 2 Phenothiazine 1 Nonsteroidal anti-inflammatory drugs 1 Tetrahydrozoline 1 Carbamazepine 1 Acetone 1 Total 208t
% 55.1 24,4 21.3 14.2 12.6 4.7 4.7 4,7 3.9 3.9 24 2,4 2.4 1.6 1.6 0.8 0.8 0.8 0.8 0.8
*Listed nonspecifically by category tSeveral patients had more than one substance present.
RESULTS
During the 12-month study period, 1,354 patients (995 male [73%] and 359 female [17%]) were admitted to the trauma service, of whom 177 (142 male [80%] and 35 female [20%]) satisfied the study criteria of altered mental status and toxicology screen being obtained. Of these, 127 (72%) tested positive for one or more substances. Only 26 patients (20%) were positive for alcohol alone. Forty-four (35%) were positive for alcohol and at least one other substance (Table 1), whereas 57 p a t i e n t s (45%) were found to have screens negative for alcohol but positive for other substances (Table 2). The most often encountered substances (Table 3) were ethyl alcohol (55%), marijuana (24%), and cocaine (21%). Ethyl alcohol was considered positive only at a serum concentration of 100 mg/dL or more. All other medications, with the exception of lidocaine and ultrashort-acting barbiturates, are listed without regard to serum levels. Review of the resuscitation of these patients in the ED and their i n p a t i e n t m a n a g e m e n t showed that none received intervenAnnals of Emergency Medicine
tions directly related to the comprehensive toxicology screen results. DISCUSSION Toxicologic screening in the El9 has been shown to be a useful adjunct in the management of poisonings and overdoses. 1-z A recent study by B a i l e y s u g g e s t e d t h a t these screens in the multiple-trauma patient m a y infrequently find drugs other than alcohol and concluded that blood ethanol levels alone may be a c o s t - e f f e c t i v e a l t e r n a t i v e to comprehensive toxicology screens. 9 The trauma patient can present a difficult diagnostic dilemma, especially when under the influence of potentially mind-altering drugs or medications. It is conceivable that some of the substances found on the positive screen could influence current trauma scores. Cocaine, for example, can elevate both pulse and blood pressure w h e n used intravenously in doses as low as 25 mg. le Smoking one marijuana cigarette has been reported to raise the pulse of a healthy subject as much as 53%. 11 Knowledge of some of these sub20:2 February 1991
TOXICOLOGY SCREEN Clark & Harchelroad
stances may also be helpful in the postresuscitation setting if the patient exhibits withdrawal signs or symptoms. We are not able to make assumptions in these areas from the above data. Although further study must be undertaken to assess the impact of substance abuse on the management of the trauma patient, several conclusions may be drawn from our survey results. With the previously listed inclusion criteria, the total number of positive screens during the study was 72%, which is very similar to the resuits obtained by Bailey. 9 However, 45% of all positive screens from our study group did not contain ethanol but were positive for at least one other substance. Twenty-six percent of positive screens contained other pharmaceuticals that could have altered the clinical presentations. This percentage is higher in our population than those previously reported. 9 The results imply trends of substance abuse in our study population. Bailey found screens positive for cocaine in 7% of trauma patients tested in 1985.9 Surveys examining ED toxicology screening in patients with histories of drug ingestion have reported similar results. Taylor et al audited toxicology screens ordered through the ED between 1981 and 1984 and found cocaine in less than 2%.4 Hepler et al also found approximately 2% of hospital toxicology screens positive for cocaine in 1984, 6 whereas Bailey recorded p o s i t i v e screens for cocaine in 1% of ED patients in 1978 and 7% in 1979. 2 Bailey repeated a variation of his previous studies from 1981 through 1984 on patients presenting to the ED with screens positive for ethanol,
20:2February1991
finding that of those testing positive for at least one other drug, cocaine was present in 5%. 5 A m p h e t a m i n e s or a m p h e t a m i n e d e r i v a t i v e s h a v e been f o u n d in screens of from 2% to 20% of patients in the above-mentioned surveys. In the present study, cocaine was found nine times more often than amphetamines and at an overall i n c i d e n c e of 21% of all positive screens, which is higher than in any previous study. This finding may reflect the present trends of substance abuse with urban communities. Finally, this survey also screened patients for THC, the incidence of which was estimated at 35% in a previous study by Soderstrom et al in 198832 The explosive increase in cocaine use in t o d a y ' s s o c i e t y has shifted media attention away from marijuana. It was found from our study that 24% of positive screens (overall incidence, 17%1 showed the presence of THC, implying continued widespread use of marijuana. CONCLUSION The results of this study indicate that other than alcohol, the most popular substances of abuse in our study population of multiple trauma patients presenting to the ED with mental status changes were cocaine and marijuana. The presence of cocaine in this group was higher than in study populations of previous surveys. As none of the patients in this group had initial ED treatment alterations in relation to their compreh e n s i v e t o x i c o l o g y screens, such screening does not appear useful .in the acute management of the trauma patient with mental status changes. Furthermore, as no alterations of in-
Annals of Emergency Medicine
patient management were found {in regard to either the acute intoxications or the chronic abuser), obtaining a screen does not appear to be an efficient use of resources if one does not act on the results. Further study is recommended to determine how much the potential physiologic abnormalities caused by these substances impact evaluation and resuscitation of these patients in the ED and how related problems, such as withdrawal, affect convalescent management during hospitalization.
REFERENCES 1. Bailey DN, Guba JJ: Survey of emergency toxicology screening in a university medical center. ] Anal Toxicot 1979;3:133-136. 2. Bailey DN, Manoguerra AS: Survey of drug-abuse patterns and toxicology analysis in an emergency-room population. [ Anal Toxicol 1980;4:199-203. 3. Soslow AR: Acute drug overdose: One hospital's experience. Ann Emerg Med 1981~10:18-21. 4. Taylor RL, Cohan SL, White JD: Comprehensive toxicology screening in the emergency department: An aid to clinical diagnosis. A m [ Emerg Med 1985~3:507-511. S. Bailey DN: Comprehensive toxicology screening: The frequency of finding other drugs in addition to ethanol. Clin Toxicol 1984;5:463-471. 6. Hepler BR, Sutheimer CA, Sunshine I: The role of the toxicology laboratory in emergency medicine: II. Study of an integrated approach. Clin Toxicol 1985;6: 503-528. 7. KeUermann AL, Fihn SD, LoGerfo JP, et al: Impact of drug screening in suspected overdose. Ann Emerg Med 1987;16:1206-1216. 8. Wihbank TB, Sine HE, Brody BV, et ah Opinion: Are emergency toxicology measurements really used? Clin Chem 1974;20:116-118. 9. Bailey DN: Comprehensive toxicology screening in patients admitted to a university trauma center. [ Anal Toxicol 1986;10:147-149. 10. Ellenhorne MJ, Barceloux DG: Medical To,~dcology: Diagnosis and Treatment of Human Poisoning. New York, Elsevier, 1988, p 651. 11. Tashkin DP, Sources JR, Hepler RS, ct a]: Cannabis, 1977. Ann Intern Med 1978~89:539-549. 12. Soderstrom CA, Trifillis AL, Shankar BS, et ah Marijuana and alcohol use among 1,023 trauma patients. Arch Surg 1988;123:733-737.
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Toxicology Screening of the Trauma Patient: A Changing Profile Study objectives: To determine the current ingestants found in the multiply injured trauma patient and to determine if this select group of ingesrants affected the resuscitation, evaluation, or convalescent management of these Patients. Design: A one-year retrospective analysis was performed on all patients who were admitted to an urban trauma center with a discharge diagnosis of multiple trauma and who received a comprehensive toxicology screening test. Main results: One hundred twenty-seven of the 177 patients (72%) who fulfilled the criteria had positive toxicology screens. Ethyl alcohol was the only drug present in 26 of thes e patients (20%); 57 (45%) were positive for drugs other than ethyl alcohol. A combination of ethyl alcohol and at least one other drug was quantified in 44 patients (35%)i The most often encountered substances were ethyl alcohol (55%), marijuana (24%), and cocaine (21%). Twelve drug screens (9%) demonstrated pharmaceuticals (eg, acetylsalicylic acid, acetaminophen, or cyclic antidepressants) that may require specific antidotal treatment. Conclusion: The ingestant profile found in this subgroup of trauma patients differed from those of previous studies. Although a select group of these ingestants require s specific treatment or affects the physical assessment of the patient, none of these trauma patients received more than supportive care. [Clark RF, Harchelroad F: Toxicology screening of the trauma patient: A changing profile. Ann Emerg Med February 1991;20:
151-153.1
Richard F Clark, MD* Phoenix, Arizona Fred Harchelroad, MDt Pittsburgh, Pennsylvania From the Department of Medical Toxicology, Good Samaritan Medical Center, Phoenix, Arizona;* and the Division of Emergency Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania.t Received for publication September 18, 1989. Revision received May 9, 1990. Accepted for publication August 1, 1990. Presented at the 1989 AAPCC/AACT/ ABMT/CAPCC Scientific Assembly in Atlanta, Georgia, October 1989. Address for reprints: Fred Harchelroad, MD, Division of Emergency Medicine, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, Pennsylvania 15212.
INTRODUCTION Comprehensive toxicology screens are used in many emergency deparb ments and trauma services to aid in the differential diagnosis of the patient with mental status changes. Although several studies 1-7 have determined the incongruence between history taking and physical examination in the emergency care setting and the occurrence of actual drugs ingested, other studies8, 9 have noted that routine comprehensive toxicology Screening may not be cost efficient in the trauma patient. Although it may be impossible to determine by physical examination alone whether the mental status and vital sign abnormalities seen in the trauma patient are secondary to head injury, hypovolemic or cardiogenic shock, substance abuse, or a combination, most patients will have multiple diagnostic and therapeutic procedures performed before completion of comprehensive toxicology screens. To question the usefulness of these screens and to note any changing trends from earlier studies, the results obtained from comprehensive toxicology screens of patients admitted to a large urban trauma service were reviewed.
MATERIALS A N D M E T H O D S Patients admitted to the trauma service with any type of altered mental status may, at the discretion of the attending physician, have a screen obtained. Several of the attending physicians obtained a screen on most of their patients; other physicians never obtained a screen on their patients. Because of the random nature of physician care, we believed that no selec-
20:2 February 1991
Annals of Emergency Medicine
151/63
TOXICOLOGY SCREEN Clark & Harchelroad
TABLE 1. Substances found in addition to ethyl alcohol in 44 patients Substance*
Cocaine Marijuana (THC) Benzodiazepines Opiates Quinine Antihistamine Cyclic antidepressant Phenobarbital Salicylate Phenylpropanolamine Meprobamate Phenothiazine Nonsteroidalanti-inflammatorydrugs Total
No. of Patients
16 14 6 4 3
2 2 2 1 1 1 1 1 54t
% 34.4
31.8 13,6 9.1 6.8 4.5 4.5 4.5 2.3 2.3 2.3 2.3 2.3
*Listed nonspedPcallyby categor~ tSeveral patients had more than one substancepresent.
tion bias existed for the entrance of these patients into the study. Comprehensive toxicology screens were not obtained on patients unless they had altered mental status. This retrospective review was performed on patients a d m i t t e d b e t w e e n April 1, 1988, and March 31, 1989. Both blood and urine specimens were obtained on these patients and evaluated as a comprehensive screen. The presence of a drug was confirmed by gas chromatography or mass spectrometry. T u r n a r o u n d time from w h e n the samples were obtained to the receipt of the final results averaged four hours. C o m p r e h e n s i v e toxicology screen results are reported as both qualitative (urine) and quantitative (blood), with the exception of marijuana, which was reported only qualitatively as THC. Inclusion criteria for the present study were a diagnosis of multiple trauma determined in the ED before admission to the trauma service, altered m e n t a l status d o c u m e n t e d since the time of the accident, and both blood and urine specimens obtained for toxicologic analysis. TO obtain a final discharge diagnosis of "multiple trauma," the patient must have had injuries to two or more organ systems. Because the physical finding of "altered mental status" is not listed on the c o m p u t e r i z e d trauma registry, it is unknown how many patients with altered mental 64/152
TABLE 2. Substances found without the presence of ethyl alcohol in 57 patients Substance*
Marijuana(THC) Opiates Cocaine Benzodiazepines Salicylate Cyclic antidepressant Phenyt°in Antihistamine Quinine Amphetamine Acetaminophen Phenylpropanolamine Meprobamate Carbamazepine Tetrahydrozoline Acetone Total
No. of Patients
17 14 11 10 5 4 3 3 3 3 3 2 1 1 1 1 82t
TABLE 3. Substances found in 127 trauma patients Substance*
%
29.8 24.5 19,2 17.5 8.7 7.0 5.3 5.3 5.3 5.3 5.3 3.5 1.8 1.8 1.8 1.8
*Usted nonspeciflcally by category. tSeveral patienls had more than one substancepresent
status were not i n c l u d e d in the study.
No. of Patients
Ethyl alcohol 70 Marijuana (THC) 31 Cocaine 27 Opiates = 18 Benzodiazepines 16 Cyclic antidepressant 6 Salicylate 6 Quinine 6 Phenytoin 5 Antihistamine 5 Phenylpropanolamine 3 Amphetamine 3 Acetaminophen 3 Meprobamate 2 Phenobarbital 2 Phenothiazine 1 Nonsteroidal anti-inflammatory drugs 1 Tetrahydrozoline 1 Carbamazepine 1 Acetone 1 Total 208t
% 55.1 24,4 21.3 14.2 12.6 4.7 4.7 4,7 3.9 3.9 24 2,4 2.4 1.6 1.6 0.8 0.8 0.8 0.8 0.8
*Listed nonspecifically by category tSeveral patients had more than one substance present.
RESULTS
During the 12-month study period, 1,354 patients (995 male [73%] and 359 female [17%]) were admitted to the trauma service, of whom 177 (142 male [80%] and 35 female [20%]) satisfied the study criteria of altered mental status and toxicology screen being obtained. Of these, 127 (72%) tested positive for one or more substances. Only 26 patients (20%) were positive for alcohol alone. Forty-four (35%) were positive for alcohol and at least one other substance (Table 1), whereas 57 p a t i e n t s (45%) were found to have screens negative for alcohol but positive for other substances (Table 2). The most often encountered substances (Table 3) were ethyl alcohol (55%), marijuana (24%), and cocaine (21%). Ethyl alcohol was considered positive only at a serum concentration of 100 mg/dL or more. All other medications, with the exception of lidocaine and ultrashort-acting barbiturates, are listed without regard to serum levels. Review of the resuscitation of these patients in the ED and their i n p a t i e n t m a n a g e m e n t showed that none received intervenAnnals of Emergency Medicine
tions directly related to the comprehensive toxicology screen results. DISCUSSION Toxicologic screening in the El9 has been shown to be a useful adjunct in the management of poisonings and overdoses. 1-z A recent study by B a i l e y s u g g e s t e d t h a t these screens in the multiple-trauma patient m a y infrequently find drugs other than alcohol and concluded that blood ethanol levels alone may be a c o s t - e f f e c t i v e a l t e r n a t i v e to comprehensive toxicology screens. 9 The trauma patient can present a difficult diagnostic dilemma, especially when under the influence of potentially mind-altering drugs or medications. It is conceivable that some of the substances found on the positive screen could influence current trauma scores. Cocaine, for example, can elevate both pulse and blood pressure w h e n used intravenously in doses as low as 25 mg. le Smoking one marijuana cigarette has been reported to raise the pulse of a healthy subject as much as 53%. 11 Knowledge of some of these sub20:2 February 1991
TOXICOLOGY SCREEN Clark & Harchelroad
stances may also be helpful in the postresuscitation setting if the patient exhibits withdrawal signs or symptoms. We are not able to make assumptions in these areas from the above data. Although further study must be undertaken to assess the impact of substance abuse on the management of the trauma patient, several conclusions may be drawn from our survey results. With the previously listed inclusion criteria, the total number of positive screens during the study was 72%, which is very similar to the resuits obtained by Bailey. 9 However, 45% of all positive screens from our study group did not contain ethanol but were positive for at least one other substance. Twenty-six percent of positive screens contained other pharmaceuticals that could have altered the clinical presentations. This percentage is higher in our population than those previously reported. 9 The results imply trends of substance abuse in our study population. Bailey found screens positive for cocaine in 7% of trauma patients tested in 1985.9 Surveys examining ED toxicology screening in patients with histories of drug ingestion have reported similar results. Taylor et al audited toxicology screens ordered through the ED between 1981 and 1984 and found cocaine in less than 2%.4 Hepler et al also found approximately 2% of hospital toxicology screens positive for cocaine in 1984, 6 whereas Bailey recorded p o s i t i v e screens for cocaine in 1% of ED patients in 1978 and 7% in 1979. 2 Bailey repeated a variation of his previous studies from 1981 through 1984 on patients presenting to the ED with screens positive for ethanol,
20:2February1991
finding that of those testing positive for at least one other drug, cocaine was present in 5%. 5 A m p h e t a m i n e s or a m p h e t a m i n e d e r i v a t i v e s h a v e been f o u n d in screens of from 2% to 20% of patients in the above-mentioned surveys. In the present study, cocaine was found nine times more often than amphetamines and at an overall i n c i d e n c e of 21% of all positive screens, which is higher than in any previous study. This finding may reflect the present trends of substance abuse with urban communities. Finally, this survey also screened patients for THC, the incidence of which was estimated at 35% in a previous study by Soderstrom et al in 198832 The explosive increase in cocaine use in t o d a y ' s s o c i e t y has shifted media attention away from marijuana. It was found from our study that 24% of positive screens (overall incidence, 17%1 showed the presence of THC, implying continued widespread use of marijuana. CONCLUSION The results of this study indicate that other than alcohol, the most popular substances of abuse in our study population of multiple trauma patients presenting to the ED with mental status changes were cocaine and marijuana. The presence of cocaine in this group was higher than in study populations of previous surveys. As none of the patients in this group had initial ED treatment alterations in relation to their compreh e n s i v e t o x i c o l o g y screens, such screening does not appear useful .in the acute management of the trauma patient with mental status changes. Furthermore, as no alterations of in-
Annals of Emergency Medicine
patient management were found {in regard to either the acute intoxications or the chronic abuser), obtaining a screen does not appear to be an efficient use of resources if one does not act on the results. Further study is recommended to determine how much the potential physiologic abnormalities caused by these substances impact evaluation and resuscitation of these patients in the ED and how related problems, such as withdrawal, affect convalescent management during hospitalization.
REFERENCES 1. Bailey DN, Guba JJ: Survey of emergency toxicology screening in a university medical center. ] Anal Toxicot 1979;3:133-136. 2. Bailey DN, Manoguerra AS: Survey of drug-abuse patterns and toxicology analysis in an emergency-room population. [ Anal Toxicol 1980;4:199-203. 3. Soslow AR: Acute drug overdose: One hospital's experience. Ann Emerg Med 1981~10:18-21. 4. Taylor RL, Cohan SL, White JD: Comprehensive toxicology screening in the emergency department: An aid to clinical diagnosis. A m [ Emerg Med 1985~3:507-511. S. Bailey DN: Comprehensive toxicology screening: The frequency of finding other drugs in addition to ethanol. Clin Toxicol 1984;5:463-471. 6. Hepler BR, Sutheimer CA, Sunshine I: The role of the toxicology laboratory in emergency medicine: II. Study of an integrated approach. Clin Toxicol 1985;6: 503-528. 7. KeUermann AL, Fihn SD, LoGerfo JP, et al: Impact of drug screening in suspected overdose. Ann Emerg Med 1987;16:1206-1216. 8. Wihbank TB, Sine HE, Brody BV, et ah Opinion: Are emergency toxicology measurements really used? Clin Chem 1974;20:116-118. 9. Bailey DN: Comprehensive toxicology screening in patients admitted to a university trauma center. [ Anal Toxicol 1986;10:147-149. 10. Ellenhorne MJ, Barceloux DG: Medical To,~dcology: Diagnosis and Treatment of Human Poisoning. New York, Elsevier, 1988, p 651. 11. Tashkin DP, Sources JR, Hepler RS, ct a]: Cannabis, 1977. Ann Intern Med 1978~89:539-549. 12. Soderstrom CA, Trifillis AL, Shankar BS, et ah Marijuana and alcohol use among 1,023 trauma patients. Arch Surg 1988;123:733-737.
153/65
