good case from Sunday

[la gringa]

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50ish lady BIB 2 roommates for AMS, low grade temp. 2 days of not acting right, slumped over, talking about things in the past. had been gone from that residence for a few weeks and just came back. patient is totally useless for hx. meds from the house: cymbalta, neurontin, klonopin, soma. old visits in the EMR just for back pain. roommates say she's always been a good roommate and they are very worried about her.

Vitals - T 100 rectal, pulse 100, BP normal, RR about 26
Exam -
mumbling, looking for her dog, talking about dead relatives
normal pupils
tachypneic, clear lungs
nontender abdomen
no skin changes
agitated, moving around the bed

doc out front ordered basic labs and a CT head...
CT head - normal except WBC 14k
CBC - normal
chem - remarkable for:
bicarb 13
BUN 35
Cr 2.4 (old from 2011 was normal)
anion gap 14 (normal in lab system)

UA - positive only for blood
CXR - lingular infiltrate

I added a few orders... what would you add or do?

 

[pianoman511]

EKG?

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[dotcb]

treat for pneumonia, admit to medicine.

All of the following need further work-up - it depends if your ED culture is such that you initiate the work-up yourself or if medicine is comfortable taking over at this point.

hematuria
altered mental status
acute kidney injury

Possible LP, possible CT KUB, bladder and renal US, CK, salicylate, patient's response to therapy, etc.

 

[southerndoc]

ABG, LP.

AMS either from hypoxia (didn't see it mentioned), hypercapnia, or concomitant meningitis (from Austrian syndrome -- pneumococcal pneumonia, meningitis, and endocarditis).

One could also argue the lingular infiltrate is from aspiration (not as common but possible). I'm still concerned about pneumonia not explaining her altered mentation, and therefore given the fever, I think an LP is warranted.

So labs I would like to see:

- O2 saturation, pO2, pCO2, pH (given bicarb 13)
- lactic acid
- CSF for cell count, gram stain, culture, glucose/protein
- serum Osm, APAP, ASA levels
- LFT's
- pregnancy test

 

[deleted109597]

CK
Benzos to treat her serotonin syndrome.
Fluids.

 

[Rendar5]

I'll be the 3rd to ask for ASA levels.

 

[Daiphon]

...as above.

Plus an ABG, an ASA level & a pharmacy consult to find me some bicarb.

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[EmergencyMonkey]

Ok. I'm an ER doc, this whole thread needs to be done in less than 2 hours or you're all getting admitted and sent upstairs 🙂

 

[Zanegray]

Benzos to treat her serotonin syndrome.
.

im thinking this

 

[la gringa]

sat was normal

i ordered:
- abg: ph 7.34, pt moving so it was a vbg, co2 22
- ekg: sinus tach, normal intervals etc
- lactate: 0.8
- LP setup and abx for possible meningitis as well as pna
- ASA level - took a while
- ativan 0.5mg IV, repeat if necessary

then i got really busy with a transfer of a pending aneurysm rupture and a tylenol overdose.

nurse came to me... ASA 54

transferred her b/c i was working at a hospital w/o dialysis capability.

thought it was interesting b/c:
1. only my 2nd salicylate toxicity ever (1st in 4 yrs as an attending)
2. dx was purely clinical ie no history at all of overdose.

 

[la gringa]

(i fell asleep about an hour after posting... my couch has ambien in it and i worked 45 hrs the last 4 days)

 

[SoCuteMD]

I would have added serum osms as well.

 

[Arcan57]

sat was normal

i ordered:
- abg: ph 7.34, pt moving so it was a vbg, co2 22
- ekg: sinus tach, normal intervals etc
- lactate: 0.8
- LP setup and abx for possible meningitis as well as pna
- ASA level - took a while
- ativan 0.5mg IV, repeat if necessary

then i got really busy with a transfer of a pending aneurysm rupture and a tylenol overdose.

nurse came to me... ASA 54

transferred her b/c i was working at a hospital w/o dialysis capability.

thought it was interesting b/c:
1. only my 2nd salicylate toxicity ever (1st in 4 yrs as an attending)
2. dx was purely clinical ie no history at all of overdose.

In residency I had a pt sent over from our psych unit because she stopped taking care of the kids and while there she complained of chest pain. She was a hard stick and got pissed off at the nurse and screamed "I just swallowed a bottle full of aspirin!" Vitals normal at this stage. By time ASA level came back (350s) she was tachypneic in the 30s and had a low grade temp. She probably would have crumped on the floor if the nurse had gotten the IV on the first attempt since we had POC troponins.

 

[Bostonredsox]

Med/CC here. From my side I would like an osmolar gap sent off by you guys. Takes a bit to come back in my lab and an AMS with acute renal failure and a metabolic acidosis with psych polypharmacy needs to have ethy glycol and methanol excluded. Rapidly.

Edit: I see someone already added serum osm to thus calculate the osmolar gap.

 

[Daiphon]

Med/CC here. From my side I would like an osmolar gap sent off by you guys. Takes a bit to come back in my lab and an AMS with acute renal failure and a metabolic acidosis with psych polypharmacy needs to have ethy glycol and methanol excluded. Rapidly.

Edit: I see someone already added serum osm to thus calculate the osmolar gap.

Might not exclude anything.

Acidemic & altered patient w/ end-organ damage (AKI suggests EtGly) may have already metabolized all the parent -OH (which will give you the mathematically flawed osmol gap) to acid byproducts (which does not give a gap).

I don't have a problem with sending it, but be aware that a non widened gap with late presentations doesn't exclude anything. You need serum levels of the ToxOH to exclude.

Cheers!
-d

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[Bostonredsox]

Might not exclude anything.

Acidemic & altered patient w/ end-organ damage (AKI suggests EtGly) may have already metabolized all the parent -OH (which will give you the mathematically flawed osmol gap) to acid byproducts (which does not give a gap).

I don't have a problem with sending it, but be aware that a non widened gap with late presentations doesn't exclude anything. You need serum levels of the ToxOH to exclude.

Cheers!
-d

Sent from my DROID BIONIC using Tapatalk

Agreed. But we cannot draw the toxic alcohols at my shop they are send outs and by the time I be them back they are no longer helpful. So osmolar gap is the only other tool I truly have. Urine microscopes analysis helps also but that can be done when they get to me. You are correct on the non exclusion for late presenters though.

 

[Arcan57]

Might not exclude anything.

Acidemic & altered patient w/ end-organ damage (AKI suggests EtGly) may have already metabolized all the parent -OH (which will give you the mathematically flawed osmol gap) to acid byproducts (which does not give a gap).

I don't have a problem with sending it, but be aware that a non widened gap with late presentations doesn't exclude anything. You need serum levels of the ToxOH to exclude.

Cheers!
-d

Sent from my DROID BIONIC using Tapatalk

I could have sworn I had run across a dosing regimen for fomepizole that used osmolar gap closure as a substitute if you couldn't get toxic alcohol levels but I can't find it now.

 

[Daiphon]

I could have sworn I had run across a dosing regimen for fomepizole that used osmolar gap closure as a substitute if you couldn't get toxic alcohol levels but I can't find it now.

Closure requires an initially widened gap... my point was that absence of a widened gap doesn't exclude poisoning.

Also, the "normal" gap of ~10 will result in serum levels of 32mg/dL for methanol & 62mg/dL for ethylene glycol... both of which still very much need fomepizole.

Gap * (molecular weight/10) = approximate serum concentration of -OH in question. MW's: MeOH 32, EtOH 46, EtGly 62.

I strongly caution against trying to follow the gap to treat these. It's not like DKA...

-d

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[gro2001]

Good case! Thanks for posting.

 

[VentdependenT]

treat for pneumonia, admit to medicine..

Brilliant

Just get em in the door...

All AMS pts getting admitted to me need a urine and serum tox.

WBC + AMS + Temp = cthead and LP. Especially if imm comp. Yes I said it. Figuring this crap out after pt gets vanc/ceftriax/acyclovir/ampicillin sucks. Do not just admit with pna and dump to floor.

All anion gap acidosis gets a osmol gap

All acidotic pts get a lactate.

Yes thank you for getting an ABG/VBG on a pt with acidosis, tachypnea, and AMS. You would be suprised how many people dont. For me the result was a big give away to underlying probable cause of her current condition.


Anyways to the OP good pickup. Pt could have easily deteriorated while being treated with IVF and azithro/rocephin for her pna.

 

[la gringa]

thanks Vent - i thought it was a fairly nerdy pickup as i know a few of my colleagues would not have worked up the acidosis...

gotta remember to order osms more.

did some f/u - pt woke up fine and was pounding goody's powders for the BACK PAIN.... very popular here in the south. basically Excedrin in a powder. very common cause of ASA overdose, accidental or intentional.

 

[VentdependenT]

thanks Vent - i thought it was a fairly nerdy pickup as i know a few of my colleagues would not have worked up the acidosis...

gotta remember to order osms more.

did some f/u - pt woke up fine and was pounding goody's powders for the BACK PAIN.... very popular here in the south. basically Excedrin in a powder. very common cause of ASA overdose, accidental or intentional.

LMAO. Glad she did ok. Did she end up gettin dialysis with the AMS and crap renal function?

Dude, I've tried Goody's. I moved to Louisville from Chicago and was in my in-laws house when I first arrived and found it in their medicine cabinet when looking for some headache relief. I was like, WTF is this hillbilly $hit? I took it, tasted horrible, worked great though!

 

[Bostonredsox]

I'm in southern VA. Goody powder, BC powder, etc are like candy down here. I've seen 6-7 NSAID overdoses already and countless UGIB's 2/2 these OTC powdered aspirins. When I was an intern I asked Melena pts do you use ASA, Motrin, ibuprofen, aleve or naprosyn? After my GI month I prefaced that list with any BC powder or goody powder...

And I agree with vent, working up the acidosis was a good job LG. so many times I get exactly what vent described. No abg no lactate no osms no urine lytes. Just Fever, AMS with serum bicarbonate of 14. Ed routinely calls me with "uti with acidosis, probably lactate". I emergently dialyzed an ethy gly OD that was missed in Ed, given to me as "idk probably septic but not sure from where".

Glad to see someone who takes pride in their wrk ups.

 

[BADMD]

Closure requires an initially widened gap... my point was that absence of a widened gap doesn't exclude poisoning...

I'm late to the party, but I'd like to second this. I actually discourage people from ordering it. It is neither a good screening test nor a good diagnostic test.

 

[Bostonredsox]

I'm late to the party, but I'd like to second this. I actually discourage people from ordering it. It is neither a good screening test nor a good diagnostic test.

If your at a rural shop like mine without toxic alcohol level capability an elevated osmolar gap with ARF and a good story is how I convinced the nephrologist to come in and dialyze my guy at 2am. No it's not a great test, but if its positive and the story fits that's significant.

 

[la gringa]

she did get dialyzed once - got better and that's how the hx came out. will have to f/u on the Cr, she's still admitted.

and yes - lots of GIB's from those powders too!

 

[VentdependenT]

I'm late to the party, but I'd like to second this. I actually discourage people from ordering it. It is neither a good screening test nor a good diagnostic test.

EKG blows for picking and ruling out MI's but we order them like there is no tomorrow. If there is a convex STE then hell yeah it guides our management. If negative and picture still fits acs then its result doesnt matter as much.

Point is that gaps are not very sensitive for certain things and are certainly not specific. However when elevated I can follow them and they do guide many of my workups and treatment endpoints. Regardless A low bicarb has to be investigated. Its definitely NOT "admit to medicine for pna."

But, I believe your main point, which is easily buried in this age of radiologic/laboratory based decision making, the overall clinical picture is THE most useful approach to guiding our thought process.

If the toxidrome fits then dont let the absence of a gap fool ya. Ive been fooled by the absence of this line of thinking in the past. "The more you know." Ahh sat morning cartoons...oh how I miss thee.

Thanks.

 

[Rendar5]

Agree with all points but Urine tox on altered patients. I find those particular tests to be dangerous as they can be very misleading and give you false reassurances and false leads.

 

[BADMD]

If your at a rural shop like mine without toxic alcohol level capability an elevated osmolar gap with ARF and a good story is how I convinced the nephrologist to come in and dialyze my guy at 2am. No it's not a great test, but if its positive and the story fits that's significant.

I don't disagree. I have actually said in my lectures that the utility of the Osmlar gap is to use as a bludgeon against the uncooperative nephrologist.

The problem is that if the story fits and you have a severely acidotic patient without an explanation, you shouldn't have to rely on a crappy test to get the nephrologist in. For example, they would need dialysis if they drank brake fluid (Diethylene Glycol) and they wouldn't necessarily have an elevated Osm gap (MW `~100 g/mol). Even for moderate amounts of methanol, which may give only very small elevations in the Osmolar gap, the acidotic patient needs dialysis. In fact, for MeOH, the patient may need dialysis for small amounts as the stuff isn't cleared by the kidneys very well.

(For completeness sake, I will note that for ethylene glycol, you can often get away without dialysis, even for patients who are fairly acidotic, although I usually recommend it. I don't like "getting away with it.")

 

[BADMD]

If the toxidrome fits then dont let the absence of a gap fool ya. Ive been fooled by the absence of this line of thinking in the past. "The more you know." Ahh sat morning cartoons...oh how I miss thee.

Basically yes. The test isn't very good, so you have to look at the result in light of the pretest/post test probability. If you think it is there, then a positive test is helpful. A negative test may not be however. If you are using it as a screening test, you can't assume that a negative test rules it out.

 

[gro2001]

Agree with all points but Urine tox on altered patients. I find those particular tests to be dangerous as they can be very misleading and give you false reassurances and false leads.

Agree 100%. There are only 2 good reasons to get the urine tox in the ER:

1) For psych patients because it might help the psychiatrists tailor their psychotherapy.
2) In pediatrics for forensic purposes.

Getting a urine tox for the work up of altered mental status is silly. It is MUCH more likely to be misleading than it is to guide therapy in the right direction.

 

[Bostonredsox]

So interestingly you touched on the presence of a high anion gap without osmolar gap in the setting of toxic alcohol ingestion as the parent alcohol may have already been metabolized to the unmeasured anions.

Was doing a CCP board review case today and was give the case of a 33 y/o female with confusion and abdominal pain. EtOH 0 RR 22

Ph 7.42 co2 35 po2 85
Na 135 K 3.7 Cl 109 Bicarbonate 23

I went through my normal work up without looking at the answer choices. That yielded no acid base disorder. Gap is normal. Pco2 is lower limit of normal as she's tachpynic. Bicarbonate is lower limit of normal. I calculated serum Osm to be 290ish. Near normal.

Hmm wtf. This smells like methanol to me but I have no acidosis at all, not even a compensated one.

I reread the stem.....mentioned at the bottom, which I didn't see initially, measured serum osm was 320.

Now I have my osmolar gap. Answer was correct, "no acid base disturbance". Answer reasoning: methanol overdose that is very early in presentation. Parent alcohol is still present thus unmeasured anions have not been created, resulting in no anion gap acidosis. However large >30 osm gap.

So what I learned between your answer and this test question, is without toxic alcohol levels, if you get an osmolar gap and a generic anion gap A/B workup, you should still get your diagnosis of toxic alcohol ingestions. reason being if the methanol has been metabolized, should get super high AG coupled with clinical suspicion, and if its early on and it hasn't been metabolized yet you will get the positive OsmGap + clinical suspicion. So in reality, unless I have a high AG that can be explained by uremia, DKA, lactate or the generic salicylate level that all these patients get in ED, it should be presumed they are toxic alcohol and treated rapidly. Osmolar gap is just a clincher.

So I stick with my original request. With your conventional A/B work up in ED, if you get a serum osm to calculate osmolar gap, between that and the presence/absence of an AG with some clinical history I should be able to find all of the toxic alcohols.

 

[Rendar5]

So interestingly you touched on the presence of a high anion gap without osmolar gap in the setting of toxic alcohol ingestion as the parent alcohol may have already been metabolized to the unmeasured anions.

Was doing a CCP board review case today and was give the case of a 33 y/o female with confusion and abdominal pain. EtOH 0 RR 22

Ph 7.42 co2 35 po2 85
Na 135 K 3.7 Cl 109 Bicarbonate 23

I went through my normal work up without looking at the answer choices. That yielded no acid base disorder. Gap is normal. Pco2 is lower limit of normal as she's tachpynic. Bicarbonate is lower limit of normal. I calculated serum Osm to be 290ish. Near normal.

Hmm wtf. This smells like methanol to me but I have no acidosis at all, not even a compensated one.

I reread the stem.....mentioned at the bottom, which I didn't see initially, measured serum osm was 320.

Now I have my osmolar gap. Answer was correct, "no acid base disturbance". Answer reasoning: methanol overdose that is very early in presentation. Parent alcohol is still present thus unmeasured anions have not been created, resulting in no anion gap acidosis. However large >30 osm gap.

So what I learned between your answer and this test question, is without toxic alcohol levels, if you get an osmolar gap and a generic anion gap A/B workup, you should still get your diagnosis of toxic alcohol ingestions. reason being if the methanol has been metabolized, should get super high AG coupled with clinical suspicion, and if its early on and it hasn't been metabolized yet you will get the positive OsmGap + clinical suspicion. So in reality, unless I have a high AG that can be explained by uremia, DKA, lactate or the generic salicylate level that all these patients get in ED, it should be presumed they are toxic alcohol and treated rapidly. Osmolar gap is just a clincher.

So I stick with my original request. With your conventional A/B work up in ED, if you get a serum osm to calculate osmolar gap, between that and the presence/absence of an AG with some clinical history I should be able to find all of the toxic alcohols.

Dunno if it's just me, but you'd be hard pressed to make me come up with methanol toxicity search off of abdominal pain, confusion, and a RR of 22 along side relatively normal basic labs..

 

[VentdependenT]

Agree 100%. There are only 2 good reasons to get the urine tox in the ER:

1) For psych patients because it might help the psychiatrists tailor their psychotherapy.
2) In pediatrics for forensic purposes.

Getting a urine tox for the work up of altered mental status is silly. It is MUCH more likely to be misleading than it is to guide therapy in the right direction.

Not when youre dealing with these people on the floor.

 

[Rendar5]

Not when youre dealing with these people on the floor.

Not sure how anything on a UDS helps you other than cocaine in ACS, CVA/TIA, szr patients. I've never seen one help in other scenarios, but I've seen plenty of people start accusing folks of abusing PCP and methadone and ecstasy when all they're really abusing is cough syrup or taking seroquel or just their own meds. I mean, really, if the toxidrome doesn't fit, you must acquit.

And where I trained on tox, the toxicologists were the ones seeing the people on the floor. serum tests, sure, uds tests? never saw them order a single one.

 

[Bostonredsox]

Dunno if it's just me, but you'd be hard pressed to make me come up with methanol toxicity search off of abdominal pain, confusion, and a RR of 22 along side relatively normal basic labs..

well it helps that it was a board question in acid/base physiology, not an actual patient walking in the door.

 

[la gringa]

Not sure how anything on a UDS helps you other than cocaine in ACS, CVA/TIA, szr patients. I've never seen one help in other scenarios, but I've seen plenty of people start accusing folks of abusing PCP and methadone and ecstasy when all they're really abusing is cough syrup or taking seroquel or just their own meds. I mean, really, if the toxidrome doesn't fit, you must acquit.

And where I trained on tox, the toxicologists were the ones seeing the people on the floor. serum tests, sure, uds tests? never saw them order a single one.

recently had a lady w/ seizure d/o and h/o benzo abuse coming in repeatedly for sz and asking for pain meds. ultimately was able to get her admitted and hopefully a bit straightened out b/c of her NEGATIVE tox screen sent by a colleague the previous day. no benzos? on them chronically? keeps seizing? easy dispo 😉

 

[VentdependenT]

Not sure how anything on a UDS helps you other than cocaine in ACS, CVA/TIA, szr patients. I've never seen one help in other scenarios, but I've seen plenty of people start accusing folks of abusing PCP and methadone and ecstasy when all they're really abusing is cough syrup or taking seroquel or just their own meds. I mean, really, if the toxidrome doesn't fit, you must acquit.

And where I trained on tox, the toxicologists were the ones seeing the people on the floor. serum tests, sure, uds tests? never saw them order a single one.

Noted. After all the replies perhaps I'll change my management. The UDS is demanded by my attendings on virtually all of these patients. They have been helpful in the past.

Thanks again.

 

[Rendar5]

Noted. After all the replies perhaps I'll change my management. The UDS is demanded by my attendings on virtually all of these patients. They have been helpful in the past.

Thanks again.

I am a bit strong-worded when it comes to UDS when it comes to straight up AMS. that said, if you are gonna use them just make sure you know your own lab's UDS since they vary a lot, and find out which benzo's and opiates are nont picked up by them and memorize a big list of cross-reactants so you know what's gonna be picked up as false positives. Where I did residency (not my tox place), the psychiatrists, who do make use of them with their own reasons, actually had a list posted on the wall of the common false negatives.

 

[bougiecric]

recently had a lady w/ seizure d/o and h/o benzo abuse coming in repeatedly for sz and asking for pain meds. ultimately was able to get her admitted and hopefully a bit straightened out b/c of her NEGATIVE tox screen sent by a colleague the previous day. no benzos? on them chronically? keeps seizing? easy dispo 😉

Many urine drug screens will miss klonopin, ativan, xanax, versed, librium.

Source: http://hqmeded.com/video/39433095

 

[WilcoWorld]

Noted. After all the replies perhaps I'll change my management. The UDS is demanded by my attendings on virtually all of these patients. They have been helpful in the past.

Thanks again.

I'm not trying to be contrary here, I'm genuinely asking. Can you describe the scenario(s) where UDS results significantly changed management?

 

[Apollyon]

I am a bit strong-worded when it comes to UDS when it comes to straight up AMS. that said, if you are gonna use them just make sure you know your own lab's UDS since they vary a lot, and find out which benzo's and opiates are nont picked up by them and memorize a big list of cross-reactants so you know what's gonna be picked up as false positives. Where I did residency (not my tox place), the psychiatrists, who do make use of them with their own reasons, actually had a list posted on the wall of the common false negatives.

Well, it's not some big hidden secret that Seroquel and Effexor cause a false positive - I mean, maybe I'm just that good (I'm not), but, between my psychatrist colleagues and me, when I tell them on the drug screen that it lit up for PCP, I review the med list and figure what it is. It's kind of a non-issue; it's not like I've called someone a PCP OD. Whatever.

 

[SoCuteMD]

So interestingly you touched on the presence of a high anion gap without osmolar gap in the setting of toxic alcohol ingestion as the parent alcohol may have already been metabolized to the unmeasured anions.

Was doing a CCP board review case today and was give the case of a 33 y/o female with confusion and abdominal pain. EtOH 0 RR 22

Ph 7.42 co2 35 po2 85
Na 135 K 3.7 Cl 109 Bicarbonate 23

I went through my normal work up without looking at the answer choices. That yielded no acid base disorder. Gap is normal. Pco2 is lower limit of normal as she's tachpynic. Bicarbonate is lower limit of normal. I calculated serum Osm to be 290ish. Near normal.

Hmm wtf. This smells like methanol to me but I have no acidosis at all, not even a compensated one.

I reread the stem.....mentioned at the bottom, which I didn't see initially, measured serum osm was 320.

Now I have my osmolar gap. Answer was correct, "no acid base disturbance". Answer reasoning: methanol overdose that is very early in presentation. Parent alcohol is still present thus unmeasured anions have not been created, resulting in no anion gap acidosis. However large >30 osm gap.

So what I learned between your answer and this test question, is without toxic alcohol levels, if you get an osmolar gap and a generic anion gap A/B workup, you should still get your diagnosis of toxic alcohol ingestions. reason being if the methanol has been metabolized, should get super high AG coupled with clinical suspicion, and if its early on and it hasn't been metabolized yet you will get the positive OsmGap + clinical suspicion. So in reality, unless I have a high AG that can be explained by uremia, DKA, lactate or the generic salicylate level that all these patients get in ED, it should be presumed they are toxic alcohol and treated rapidly. Osmolar gap is just a clincher.

So I stick with my original request. With your conventional A/B work up in ED, if you get a serum osm to calculate osmolar gap, between that and the presence/absence of an AG with some clinical history I should be able to find all of the toxic alcohols.

There's this really nice graph I saw when I was on tox on anion gap and osmolar gap over time. Essentially, as the osmolar gap closes, the anion gap opens which makes sense looking at metabolic pathways. Knowing and recognizing this saved me when I caught a late presentation of methanol poisoning.

 

[Daiphon]

There's this really nice graph I saw when I was on tox on anion gap and osmolar gap over time. Essentially, as the osmolar gap closes, the anion gap opens which makes sense looking at metabolic pathways. Knowing and recognizing this saved me when I caught a late presentation of methanol poisoning.

We call it the "Mycyk Mountain.". d=)

http://www.ncbi.nlm.nih.gov/pubmed/12898493/?

Cheers!
-d

Sent from my DROID BIONIC using Tapatalk

 

[VentdependenT]

I'm not trying to be contrary here, I'm genuinely asking. Can you describe the scenario(s) where UDS results significantly changed management?

We get these wacked out aggressive motherfukers who do god knows what and having all that crap in their system, after ruling out other causes, gives us an explination and allows us to not write for controlled substances.

Methadone abusers.

flexeril/seroquel/benadryl OD's show TCA's.

TCA od's

I have to figure these people out, manage, and dispo them for follow up. This stuff can definitely help.

Etc.

 

[bougiecric]

I'm not following your explanations.

We get these wacked out aggressive motherfukers who do god knows what and having all that crap in their system, after ruling out other causes, gives us an explination and allows us to not write for controlled substances.

Why do you need a UDS to avoid writing controlled substances to a "whacked out aggressive MFer"? Are you saying that if the UDS were negative, you'd give them controlled substances at discharge?

Methadone abusers.

Again, very confused by this; can't figure out the scenario where the UDS changes management. Case 1: dude comes in breathing 4 times/min, unresponsive: narcan and/or airway protection. No UDS needed. Case 2: dude is sleepy but protecting airway. Tells you he takes methadone. No UDS needed. Case 3: dude is sleepy but protecting airway. Took some friend's pills, but doesn't know what. You admit him until he clears. No UDS needed.

Methadone does have an antidote, narcan, but it's given clinically and not based on a drug screen.

flexeril/seroquel/benadryl OD's show TCA's.

Doesn't this argue against a UDS? If they tell you they took flexeril/seroquel/benadryl, then case solved -- no need for UDS. If they don't know what they took, and you get a UDS, then having TCAs light up will only serve to muddy the picture if they truly took something else.

Not to mention, an overdose of all of the above is supportive care 99% of the time.

TCA od's

If they have they have history of taking TCAs and a concerning EKG, no UDS needed.

... all that said, I'm admittedly a big hypocrite. Nobody accepts a psych patient without a drug screen (amongst all the other useless tests), so I order them routinely. As well, when admitting an AMS patient, I'm routinely asked to "add on a drug screen." Sometimes it's just easier to acquiesce. After all, the patient isn't under my care any longer -- it's not up to me to dictate management once they're on the floor.

 

[VentdependenT]

Whatever you say dude.

I just spent an hour reading about clinical utility of UDS and indeed they seem to be worthless. I have been indoctrinated and our ED has acquiesced to avoid arguements.

I seriously thought these things were worthwhile.

I have used them to tell pts once they wake up that we found x,y,z and that they need help. I have used it to deny short courses of opiates in "whacked out mofos" once discharged. They have alteted which BB i give to the weekend warrior who comes in with an nstemi and is cocaine +

But as for acute AMS it just has been ordered because thats what they did before me.

 

[la gringa]

another utility: people who smoked weed laced w/ PCP. "hey, guess what, there was PCP in your weed.... another reason buying illegal drugs is bad etc".

 

[WilcoWorld]

We get these wacked out aggressive motherfukers who do god knows what and having all that crap in their system, after ruling out other causes, gives us an explination and allows us to not write for controlled substances.

Methadone abusers.

flexeril/seroquel/benadryl OD's show TCA's.

TCA od's

I have to figure these people out, manage, and dispo them for follow up. This stuff can definitely help.

Etc.

Gotcha. A positive UDS helps you discharge a patient who has gotten better and doesn't need the hospital anymore. And if someone put's it that way, sure, I'll order it for you. It's oddly heartening to see that, for both of us, it's all about the dispo. It reminds me of a conversation I had regarding a soft admit for a 90 year old today. Admitting doc asked if the patient lives alone- when I replied that the nonagenarian came from an assisted living facility, her sigh of relief was audible.

My only request is that you not block while waiting for UDS results. I know my dispo well before it's back, and I've got middle aged chest pains, female abdominal pains and pediatric fevers in the waiting room. But you seem like you'd get that.