![](media/image1.png){width="5.96875in" height="0.41944444444444445in"}

Top of Form

## Complete Summary

#### GUIDELINE TITLE

Recommendations for the use of laboratory tests to support poisoned
patients who present to the emergency department.

#### BIBLIOGRAPHIC SOURCE(S)

Wu AH, McKay C, Broussard LA, Hoffman RS, Kwong TC, Moyer TP, Otten EM,
Welch SL, Wax P. National Academy of Clinical Biochemistry laboratory
medicine practice guidelines: recommendations for the use of laboratory
tests to support poisoned patients who present to the emergency
department. Clin Chem 2003 Mar;49(3):357-79. \[118 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12600948)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Poisoning

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Screening

#### CLINICAL SPECIALTY

Emergency Medicine\
Internal Medicine

#### INTENDED USERS

Clinical Laboratory Personnel\
Emergency Medical Technicians/Paramedics\
Physicians

#### GUIDELINE OBJECTIVE(S)

To present recommendations on the use of clinical laboratory tests to
support the diagnosis and management of the poisoned patient who
presents to the emergency department

#### TARGET POPULATION

Patients with suspected poisoning presenting to the emergency department

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Drug testing to support emergency department (ED) toxicology
    including

    -   Stat quantitative serum or plasma toxicology assays

    -   Stat qualitative urine toxicology

    -   Comprehensive or broad-spectrum urine drug screen including
        thin-layer chromatography, liquid chromatography, gas
        chromatography (GC) with mass spectrometry (MS), and liquid
        chromatography-tandem MS

2.  Analytical and reporting issues for drugs-of-abuse testing by
    immunoassays

    -   Establishing close relationship between the clinical laboratory
        and ED and understanding the limitations of existing
        immunoassays

    -   Listing the major cross-reaction substances for each drug class

    -   Targeting antibodies in immunoassays for testing benzodiazepines
        toward the parent compound and conjugated metabolites or
        utilizing online hydrolysis

    -   Detecting most opioids (e.g., oxycodone, hydromorphone,
        meperidine, tramadol, buprenorphine, etc) and not just codeine
        and morphine

    -   Directing immunoassays for amphetamines toward a broad spectrum
        of amines as a class

    -   Confirmation of positive immunoassays if needed

3.  Specific analysis of ethyl alcohol and other toxic alcohols

    -   Establishing quality assurance (QA) and quality-control (QC)
        program for clinical breath alcohol testing

    -   Utilizing essential operator procedures for breath alcohol
        analysis

    -   Selection and validation of breath alcohol devices

    -   Direct measurements for methanol and ethylene glycol in serum or
        plasma

    -   GC or \"Acetest\" for detection of isopropyl alcohol and
        propylene glycol

4.  Laboratory assays for other toxicants

    -   Quantitative serum or plasma acetaminophen assay

    -   Screening for salicylate by assessing patient\'s signs and
        symptoms

    -   History and physical examination for determining the exposure to
        cyanide or hydrogen sulfide

    -   Monitoring for coagulation status by the prothrombin time (PT)
        test for determining exposure to anticoagulants

    -   Heparinized blood samples for lead testing

    -   History and clinical examination, serum or plasma transferrin
        measurement or direct unsaturated iron-binding capacity (UIBC)
        assay to identify iron poisoning

    -   A 12- or 24-hour timed urine collection in a metal-free
        container for arsenic and mercury analysis

    -   Stat pseudocholinesterase testing to screen for exposure to
        pesticides

    -   Recognizing signs of inhalant abuse

    -   Measurement of the fraction of oxyhemoglobin with a co-oximeter

    -   Establishing regional toxicology centers to serve the
        toxicologic needs of a larger community of medical centers

**Tests Considered but Not Recommended**

-   Regular testing of urine for benzodiazepines

-   Stat testing for the following drugs for ED patients with acute
    symptoms: tetrahydrocannabinol (THC; marijuana), lysergic acid
    diethylamide (LSD), methaqualone, ibuprofen, and cotinine (nicotine
    metabolite).

-   Specific drug test panels based on toxidromes

-   Testing of gastric contents in clinical management

-   Maintenance of chain-of-custody documentation for samples collected
    for clinical toxicology purposes

-   Broad-spectrum screening for trace elements or other analytes in the
    absence of probable cause

#### MAJOR OUTCOMES CONSIDERED

-   Prevalence of drug and alcohol use in association with emergency
    department visits

-   Sensitivity and specificity of laboratory tests

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Recommendations for the use of clinical laboratory tests were prepared
by an expert panel of analytical toxicologists and emergency department
(ED) physicians specializing in clinical toxicology. These
recommendations were posted on the worldwide-web and presented in open
forum at several clinical chemistry and clinical toxicology meetings
during the year 2001: a local clinical chemistry section meeting at the
Royal Brisbane Hospital (Brisbane, Australia) in January; the Midwest
Association for Toxicology and Therapeutic Drug Monitoring, William
Beaumont Hospital (Royal Oak, MI), in May; Edutrak Sessions at the
American Association of Clinical Chemistry (AACC) Annual Meeting
(Chicago, IL) in August; and in October, The North American Congress of
Clinical Toxicology (Montreal, Canada), The Society of Forensic
Toxicology (New Orleans, LA), and the Scientific Assembly Toxicology
Section meeting of the American College of Emergency Physicians
(Chicago, IL). Participants at each meeting discussed the merits of the
recommendations. A summary of these discussions are presented in the
original guideline document.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions for the degree of consensus (A or B) are provided at the end
of the \"Major Recommendations\" field.

**General Principles for Drug Testing to Support Emergency Department
(ED) Toxicology**

*Tier I Toxicology Testing*

**Guideline 1.**

The clinical laboratory should provide two tiers of drug testing. The
first tier includes stat testing of selected target quantitative tests
in serum or plasma (see Table 1 below) and qualitative tests in urine
(see Table 2 below). If the patient is in no acute distress, additional
or even most initial toxicology testing may be unnecessary.

***Degree of consensus*: A** for the analytes listed in Table 1, **B**
for the analytes listed in Table 2.

**Table 1. Stat quantitative serum toxicology assays required to support
an ED\***

-   Acetaminophen (paracetamol)

-   Lithium

-   Salicylate

-   Co-oximetry for oxygen saturation, carboxyhemoglobin, and
    methemoglobin

-   Theophylline

-   Valproic acid

-   Carbamazepine

-   Digoxin

-   Phenobarbital (if urine barbiturates are positive)

-   Iron

-   Transferrin (or unsaturated iron-binding capacity \[UIBC\] assay if
    transferrin is not available)

-   Ethyl alcohol

-   Methyl alcohol\*\*

-   Ethylene glycol\*\*

\*Turnaround time (TAT) of 1 hour or less.

\*\*More realistic TATs for these assays are 2-4 hours. These tests are
largely unnecessary in countries where these agents are not widely
available.

**Table 2. Stat qualitative urine toxicology assays required to support
an ED\***

-   Cocaine

-   Opiates

-   Barbiturates

-   Amphetamines\*\*

-   Propoxyphene\*\*

-   Phencyclidine (PCP\*\*)

-   Tricyclic antidepressants (TCAs\*\*\*)

\*In general, urine toxicology screens such as these have a lower
urgency and utility than do serum assays. They do not correlate well
with clinical effects and suffer from problems with sensitivity and
specificity, as discussed in the text. Although widely available, these
assays (with the exception of that for the cocaine metabolite) require
clinical interpretation.

\*\*Need for these assays may be based on prevalence of drug use, which
may vary from region to region. Regular review of drug usage is
important.

\*\*\*Recommended only if the clinical staff fully understands the
specificity limitations of this assay (i.e., results are used in
conjunction with the electrocardiograph to support a clinical suspicion
of TCA toxicity, but not in cases where a positive urine drug test is
the sole evidence for this suspicion.)

*Assay Turnaround Times for Tier I Tests*

**Guideline 2.**

The ideal TAT for Tier 1 toxicology tests is 1 hour or less except where
noted on Table 2.

***Degree of consensus*: B**

*Tier II Testing: Comprehensive or Board-spectrum Testing*

**Guideline 3.**

The second tier of drug tests is for patients admitted to the hospital
who remain intoxicated, obtunded, or comatose, where a broad-spectrum
(\"comprehensive\") screening panel and would not be identified based on
the findings of the first tier of laboratory tests. Results of these
tests might be used for more long-term management and/or counseling of
patients. Laboratorians should work closely with intensive care
providers to determine the appropriate menu of tests and TATs that are
necessary.

***Degree of consensus*: B** is necessary to cover drugs and substances
that may have clinical significance

**Guideline 4.**

Testing for toxins beyond those outlined in Tables 1 and 2 should be
performed only after the patient is stabilized and the attending
physician has received toxicology input from a poison control center or,
preferably, bedside evaluation by personnel trained in medical
toxicology.

***Degree of consensus*: A**

*Selectivity of Testing*

**Guideline 5.**

Stat testing for the following drugs is not recommended for ED patients
presenting with acute symptoms: tetrahydrocannabinol (THC; marijuana),
lysergic acid diethylamide (LSD), methaqualone, ibuprofen, and cotinine
(nicotine metabolite). Testing for some other drugs, such as
amphetamines, PCP, and propoxyphene, should be conducted in areas where
these drugs exhibit notable prevalence.

***Degree of consensus*: B**

*Drug Panel by \"Toxidromes\"*

**Guideline 6.**

Clinical laboratories should not set up specific drug testing panels
based on toxidromes. The failure to recognize a particular toxidrome may
lead to the failure to order an important drug test.

***Degree of consensus*: A**

*Gastric Samples*

**Guideline 7.**

There is no role for the testing of gastric contents in clinical
management, although premortem collection and specimen retention may be
important for cases with medico-legal considerations.

***Degree of consensus*: A**

*\"Chain-of-Custody\" for Clinical Specimens*

**Guideline 8.**

Maintenance of chain-of-custody documentation is unnecessary for samples
collected for clinical toxicology purposes, and such practice should be
discouraged. As with any laboratory specimen, proper procedures for
collection, transport, results reporting, and storage are necessary.

***Degree of consensus*: A**

**Recommendations of Analytical and Reporting Issues for Drug-of-Abuse
Testing by Immunoassays**

*Immunoassays*

**Guideline 9.**

Optimum use of urine drug testing assays for ED patients requires an
understanding of the limitations of existing commercial immunoassays for
drugs of abuse. A close relationship between the clinical laboratory and
ED staffs is necessary. The laboratory should clearly communicate to the
ED staff the extent of the toxicology services available to them, such
as the menu, target TATs, cross-reactivity data, and contact information
for consultations.

***Degree of consensus*: A**

*Listing of Cross-Reacting Substances on Immunoassays*

**Guideline 10.**

When immunoassays are used, the laboratory should list the major
cross-reacting substances for each drug class when a positive result is
reported. It may also be appropriate to indicate in a final report
(e.g., in the \"notes\" section) that a negative urine drug result does
not indicate absence of all drugs of abuse.

***Degree of consensus*: A**

*Immunoassay Cutoffs*

**Guideline 11.**

Cutoff concentrations optimized for workplace drug testing are not
necessarily appropriate for clinical toxicology. Although a
true-positive result indicates use, it does not presume impairment or
intoxication of the patient at the time of specimen collection.

***Degree of consensus*: A**

*Inadequate Spectrum of Benzodiazepine Detection by Immunoassays*

**Guideline 12.**

Some immunoassays for testing benzodiazepines are inadequate. Antibodies
in optimum assays should be targeted toward the parent compound and
principal conjugated metabolites or should utilize an online hydrolysis
procedure to convert the conjugated metabolites to the unconjugated
forms.

***Degree of consensus*: A**

**Guideline 13.**

Antibodies for benzodiazepines should be updated to identify the newer
drugs in this class as they become approved and available for clinical
use.

***Degree of consensus*: A**

*Opiate versus Opioid Detection by Immunoassay*

**Guideline 14.**

Immunoassays should detect most opioids (e.g., oxycodone, hydromorphone,
meperidine, tramadol, buprenorphine, propoxyphene, and pentacozine) and
not just codeine and morphine.

***Degree of consensus*: B**

*Immunoassays for Amphetamines versus Sympathomimetic Drug Class*

**Guideline 15.**

The optimum immunoassays to test for amphetamines in ED patients are
those directed toward a broad spectrum of amines as a class, rather than
assays that are directed specifically toward the illicit amines. An
assay directed toward phenylethyl amines would largely cover this class.
The name of the test should be changed from \"amphetamines\" to
\"sympathomimetic amines\" or \"stimulant amines.\"

***Degree of consensus*: A**

*Confirmation of Positive Immunoassays*

**Guideline 16.**

When reporting results of immunoassay screening, there must be proper
notation given that the assay used is considered as a \"screening
test\'\' and that any positive results are to be considered as
\"presumptive\'\'.

***Degree of consensus*: A**

**Guideline 17.**

The laboratory should not routinely perform confirmative analyses on
positive screening results.

***Degree of consensus*: A**

**Guideline 18.**

When confirmation is needed, the laboratory should store these specimens
for an indefinite period or until the case is resolved. The laboratory
should consult with the hospital\'s risk management department for
further guidance.

***Degree of consensus*: B**

**Recommendations for Specific Analysis of Ethyl Alcohol and Other Toxic
Alcohols**

*Need for a Breath Alcohol Quality-Assurance/Quality-Control Program*

**Guideline 19.**

Clinical breath alcohol testing is point-of-care (POC) testing and must
meet the same quality-assurance (QA)/quality-control (QC) requirements
as any POC test. As a part of the laboratory\'s ongoing QA effort, a
program must be in place to monitor and evaluate policy, protocols, and
the total testing process so that breath alcohol results are accurate
and reliable. The clinical laboratory should be involved in the design,
implementation, and monitoring of the quality assurance program.

***Degree of consensus*: A**

*Selection and Validation of Breath Alcohol Analysis*

**Guideline 20.**

The laboratory should be involved in the selection, validation, and
deployment of the breath alcohol devices used.

***Degree of consensus*: A**

*Reporting Units for Ethyl Alcohol*

**Guideline 21.**

Alcohol concentrations should be reported in units clearly defined by
the laboratory, with a notation as to the sample matrix that was tested
(serum or plasma, urine, whole blood, breath) and methodology.

***Degree of consensus*: A**

*Assays for Methanol and Ethylene Glycol*

**Guideline 22.**

Clinical laboratories should provide direct measurements for methanol
and ethylene glycol in serum or plasma. If gas chromatography (GC), the
assay should target glycolic acid, the toxic metabolite, in addition to
the parent intoxicant, ethylene glycol.

***Degree of consensus*: B**

*Osmolality Measurement for Toxic Alcohol Surveillance*

**Guideline 23.**

Inherent problems with the measured osmolality and calculation of the
osmolal gap reduce the reliability of these measurements in the
differential diagnosis of volatile and ethylene glycol alcohol
intoxication in patients. A very high osmolal gap (e.g., \> 50 mOsm/kg)
requires investigation of a toxic alcohol or other agents that can
increase the osmolality.

***Degree of consensus*: B**

*Isopropyl Alcohol, Propylene Glycol Intoxication and Acetoacetic Acid*

**Guideline 24.**

Quantification of isopropyl alcohol and propylene glycol by GC is the
preferred approach to their identification. Measurement of lactate is
appropriate for monitoring patients exposed to propylene glycol because
this is the major metabolite.

***Degree of consensus*: A**

**Guideline 25.**

Because propylene glycol is used as a vehicle in some drug preparations
and there can be inadvertent exposure, this alcohol should not be used
as an internal standard for the GC analysis of volatile alcohols.

***Degree of consensus*: A**

**Guideline 26.**

In the absence of GC testing for isopropanol, the \"Acetest\" may be
used as an insensitive surrogate because there is some reactivity of
this reagent toward acetone. However, the name of the test should be
listed as \"acetoacetic acid\" and not \"ketones,\" \"ketone bodies,\"
or \"acetone,\" as this test has the highest sensitivity toward
acetoacetic acid.

***Degree of consensus*: A**

**Recommendations on Laboratory Assays for Other Toxicants as Causes of
Poisonings**

*\"Universal\" Acetaminophen and Salicylate Screening*

**Guideline 27.**

All ED patients who present with intentional drug ingestion and chronic
overuse secondary to chronic pain should be screened with a quantitative
serum or plasma acetaminophen assay.

***Degree of consensus*: A** for quantitative serum or plasma screen.

**Guideline 28.**

Screening for the presence of salicylate can be guided by clinical
findings or acid-base abnormalities.

***Degree of consensus*: A**

*Cyanide and Hydrogen Sulfide*

**Guideline 29.**

The ED must rely on history and physical examination to determine
whether treatment with cyanide antidote is appropriate. Collection of a
blood sample for later cyanide and sulfide testing may be useful to
document exposure.

***Degree of consensus*: A**

*Anticoagulants*

**Guideline 30.**

Patients who intentionally ingest anticoagulants, particularly the
long-acting formulations, should be monitored for coagulation status by
the prothrombin time (PT) test. Samples should be collected at 24-36
hours after exposure to monitor anticoagulation effects without
prophylactic vitamin K administration. There is no stat clinical need
for determining the identity or concentration of the specific
anticoagulant taken.

***Degree of consensus*: A**

*Lead Poisoning*

**Guideline 31.**

Emergency testing for lead is not required to support ED practice. The
ED should be prepared to collect heparinized blood samples for lead
testing when lead exposure is suspected; however, specific treatment is
usually not initiated in the ED. Because lead is ubiquitous in the
environment, needles and collection and transfer tubes need to be free
of lead contamination (\<5 micrograms/L). Next-day availability of the
blood lead result is adequate to ensure appropriate follow-up.
Collection of serum or plasma for lead evaluation is not appropriate.
The erythrocyte protoporphyrin (EPP) test is not useful for detecting
low-level exposure.

***Degree of consensus*: A**

*Testing for Iron Toxicity*

**Guideline 32.**

The clinical laboratory should be prepared to provide serum or plasma
iron results on a stat basis to aid in the diagnosis of iron overdose.
Because of analytical limitations, heterogeneous assays for the total
iron-binding capacity (TIBC) cannot be used to determine the absence of
free iron and toxicity. Serum or plasma transferring is a more reliable
marker for estimating free and potentially toxic iron. If this assay is
not available on a stat basis, the homogeneous unsaturated iron-binding
capacity (UIBC) assay is more useful than TIBC assays that require a
pretreatment step.

***Degree of consensus*: A**

*Arsenic and Mercury*

**Guideline 33.**

A 12- or 24-hour timed urine collection in a metal-free container (use
opaque plastics with no metal caps) is the best sample for arsenic and
mercury analysis and falls outside the realm of ED practices. Results of
urine testing should be available within 48 hours of specimen
collection.

***Degree of consensus*: A**

*Broad-Spectrum Screening for Trace Elements and Environmental
Pollutants*

**Guideline 34.**

In the absence of probable cause, such as occupational and/or accidental
environmental exposure, broad-spectrum screening for trace elements or
other analytes is inappropriate and would rarely be indicated in the ED
or any general office practice. These tests have not been sufficiently
validated in a general patient population, nor have the implications of
clinical decisions based on one-time measurements been discussed
sufficiently to warrant any use other than research and biomonitoring
for occupational exposure.

***Degree of consensus*: B**

*Pesticides*

**Guideline 35.**

Clinical laboratories should provide access to stat pseudocholinesterase
testing to screen for exposure to cholinergic agents and not for
monitoring of therapy.

***Degree of consensus*: B**

*Inhalants*

**Guideline 36.**

Because of a lack of stat availability, there are no clinical laboratory
tests that are currently appropriate for monitoring acute inhalant abuse
or solvent exposure.

***Degree of consensus*: A**

*Methemoglobinemia*

**Guideline 37.**

For patients suspected of having methemoglobinemia, measurement of the
fraction of oxyhemoglobin (oxygen saturation) should be performed with a
co-oximeter and not a pulse oximeter, as the latter overestimates the
actual O~2~ saturation. If a request for oxygen saturation is received,
all results of a four-part co-oximetry panel should be reported even if
the specific requests for carboxyhemoglobin and methemoglobin are not
received. Laboratories should not charge separately for the inclusion of
these additional results.

***Degree of consensus*: A**

*Regional Toxicology Centers*

**Guideline 38.**

A cooperative effort should be made to establish regional toxicology
centers where specialized methods can be made available to service the
toxicologic needs of a larger community of medical centers.

***Degree of consensus*: A**

**[Definitions]{.underline}**:

**Degree of consensus**:

**A** - indicates general consensus by most participants

**B** - indicates either no consensus or that the recommendation was not
applicable to all situations

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation. The guideline recommendations are based upon expert
consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Appropriate use of laboratory tests to support poisoned patients
    presenting to the emergency department

-   Development of new and improved toxicology tests

#### POTENTIAL HARMS

False-positive and/or false-negative laboratory test results

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   The material in this monograph represents the opinions of the
    editors and does not represent the official position of the National
    Academy of Clinical Biochemistry or any of the co-sponsoring
    organizations. The National Academy of Clinical Biochemistry is the
    official academy of the American Association for Clinical Chemistry.

-   These recommendations identify laboratory support measures that can
    improve patient care. They will need to be adapted to specific
    situations, such as the evaluation of possible child abuse or
    so-called emergency psychiatric clearance. They do not address every
    question or identify every substance that might cause an individual
    to seek emergency care. For example, certain substances are
    explicitly identified as not requiring stat analytic identification,
    whereas many are not mentioned at all. The former are often agents
    that manufacturers have historically included on instrument menus or
    that certain third-party regulators or agencies have required. When
    there is no current rationale for these practices, the guideline
    developers hope this document can be used cooperatively by
    laboratory and emergency department (ED) directors and their
    respective organizations in concert with manufacturers to make
    changes locally and nationally. On the other hand, these
    recommendations are designed to be useful to the \~30,000 physicians
    making decisions in EDs across the US. As such, they do not
    represent the minimum laboratory evaluation that may be used by a
    specialist in medical toxicology, nor do they reflect all of the
    current analytic limitations present in various areas of the
    country. However, they can serve as a forum for discussion of the
    toxicology laboratory support that can and should be provided within
    a given patient population, institution, or geographic region of the
    country.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Wu AH, McKay C, Broussard LA, Hoffman RS, Kwong TC, Moyer TP, Otten EM,
Welch SL, Wax P. National Academy of Clinical Biochemistry laboratory
medicine practice guidelines: recommendations for the use of laboratory
tests to support poisoned patients who present to the emergency
department. Clin Chem 2003 Mar;49(3):357-79. \[118 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12600948)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Mar

#### GUIDELINE DEVELOPER(S)

National Academy of Clinical Biochemistry - Professional Association

#### SOURCE(S) OF FUNDING

National Academy of Clinical Biochemistry

#### GUIDELINE COMMITTEE

Guidelines Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Larry A. Broussard, Ph.D., Department of Clinical
Laboratory Sciences, Louisiana State University Health Sciences Center,
New Orleans, LA; Robert S. Hoffman, M.D., Department of Emergency
Medicine, Bellevue Hospital Center, New York, NY; Tai C. Kwong, Ph.D.,
Department of Pathology and Laboratory Medicine, University of Rochester
Medical Center, Rochester, NY; Charles McKay, M.D., Department of
Emergency Medicine, Medical Toxicology, Hartford Hospital, Hartford, CT;
Thomas P. Moyer, Ph.D., Department of Laboratory Medicine and Pathology,
Mayo Clinic, Rochester, MN; Edward M. Otten, M.D., Department of
Emergency Medicine, University of Cincinnati Hospital, Cincinnati, OH;
Paul Wax, M.D., Department of Medical Toxicology Good Samaritan Regional
Medical Center, Phoenix, AZ; Shirley L. Welch, Ph.D., Department of
Pathology, Kaiser Permanente Regional Laboratory, Clackamas, OR; Alan
H.B. Wu, Ph.D., Department of Laboratory Medicine, San Francisco General
Hospital and the University of California, San Francisco, San Francisco,
CA

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the National Academy of Clinical
Biochemistry (NACB) Web site:

-   [Portable Document Format
    (PDF)](http://www.nacb.org/lmpg/emergency/emergency_lmpg.pdf)

-   [Word Format](http://www.nacb.org/lmpg/emergency/emergency_lmpg.doc)

Print copies: National Academy of Clinical Biochemistry publications are
available through American Association for Clinical Chemistry (AACC)
Press. To make a purchase or request a catalog, contact AACC Customer
Service at 202-857-0717 or <custserv@aacc.org>.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on May 9, 2006. The information
was verified by the guideline developer on June 6, 2006.

#### COPYRIGHT STATEMENT

National Academy of Clinical Biochemistry\'s (NACB) terms for
reproduction of guidelines are posted with each set of guidelines.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

Bottom of Form

© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008