Emergency Toxicology

Emergency toxicology focuses on the diagnosis, management, and prevention of poisonings due to drugs, occupational and environmental toxins, and biological agents. Examples of exposures include acute drug overdoses, hazardous exposures to chemical products, and the management of drug withdrawal syndromes.

Tabs Content

Clinical Overview

Quick Answers

When should specimens be collected for emergency toxicology testing?

In emergency situations, there are no specific timing recommendations; instead, specimens should be collected as soon as possible.

Which specimen is appropriate for emergency toxicology testing?

Whole blood, serum, or plasma specimens are typically preferred for most testing; quantitative results can be used to assess signs and symptoms of toxicity. Urine can be used to assess acute or chronic exposure.

How should toxicology test results be interpreted?

Test results should be interpreted relative to the established therapeutic or toxic range (if applicable), timing of specimen collection relative to the time of exposure, specimen type, and the patient’s clinical signs and symptoms of toxicity. Concomitant medications and factors relevant to the window of detection will also affect the interpretation of results (see Frequently Asked Questions). Whole blood, serum, and plasma specimens can be used to assess symptoms of toxicity. Adverse drug responses can occur even when the drug concentrations are within the therapeutic range. Urine specimens can be used to assess patient exposure within an average window of detection of 1-3 days. Testing can be used for serial monitoring to determine if treatment was effective and if the concentration of the toxin has decreased over time.

Indications for Testing

Testing for toxicity may be indicated in the following situations:

Accidental or intentional poisoning from illicit or licit substances
Decontamination or detoxification
Suspected overdose of licit or illicit substances in a patient presenting with altered cognition
Metabolic acidosis of unknown cause
Signs and symptoms of toxicity in the event of a known or suspected hazardous exposure

Timing of Specimen Collection

In an acute emergency, specimens should be collected as soon as possible if toxicity is suspected. If assessing decontamination or detoxification (eg, in the case of Tylenol poisoning), retest intervals are determined on a case-by-case basis.

Specimen Selection

Whole blood, serum, or plasma is used for most testing and can provide both quantitative and qualitative information. Urine may be used in select cases when only qualitative information is needed.

Frequently Asked Questions

What is the definition of half-life?

The half-life of a drug refers to the time it takes for 50% of the drug to be eliminated from blood.

What is the definition of steady-state concentration?

Steady-state concentration occurs when the rate of drug administration is equal to the rate of elimination. Generally, steady-state concentration can be achieved after an individual has consistently administered the drug for the duration of 5-7 half-lives (eg, if a drug has a half-life of 24 hours and is administered once a day, then steady-state concentration can be achieved after 5-7 days of drug administration).

What is the window of detection of drugs in blood, serum, plasma, and urine specimens?

In general, the window of detection in blood, serum, and plasma is 1-2 days after drug administration. Urine specimens typically have an average window of detection of 1-3 days.

The window of detection for drugs is dependent on several factors, including the following:

Half-life of the drug
Drug dose
Frequency of drug administration
Route of administration
Drug formulation
Chemistry of the drug (eg, solubility, stability)
Patient’s age
Patient’s body composition and sex
Patient’s pathophysiology and pharmacokinetics
Coadministration of other medications
Hydration and nutrition status
Analytical limitations of testing

Can gel separator tubes be used for toxicology testing?

Gel separator tubes are not recommended for testing in toxicology. Drugs that are lipid soluble may be absorbed into the gel, which may cause a falsely low result.

Additional Resources

ARUP Lab Tests

Note: Refer to ARUP Consult’s Alcohol Use Biomarkers and Metabolic Acidosis topics for more testing options.

Monitor exposure to acetone

Acetone, Quantitative 0090005

Method: Quantitative Gas Chromatography

Toxic level: >100 mg/dL

Use to identify ethanol, methanol, isopropanol, or acetone ingestion

Alcohols 0090131

Method: Quantitative Gas Chromatography

Toxic level:

Isopropanol: >50 mg/dL
Acetone, quantitative: >100 mg/dL
Ethanol: >250 mg/dL
Methanol: >20 mg/dL

Serum test to identify acute alcohol ingestion

Ethanol, Serum or Plasma - Medical 0090120

Method: Quantitative Gas Chromatography

Toxic level: >250 mg/dL

Useful for general screening in the assessment of ethanol exposure in the context of compliance and/or abuse

Ethyl Glucuronide Screen with Reflex to Confirmation, Urine 2007912

Method: Qualitative Enzyme Immunoassay/Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Aid in assessment of the etiology of anion gap acidosis

Determine whether ethylene glycol poisoning exists

Ethylene Glycol 0090110

Method: Quantitative Enzymatic

Toxic level: >20 mg/dL

Monitor exposure to isopropanol

Isopropanol (Includes Acetone) 0090144

Method: Quantitative Gas Chromatography

Toxic level:

Isopropanol: >50 mg/dL
Acetone, quantitative: >100 mg/dL

Monitor exposure to methanol

Methanol 0090165

Method: Quantitative Gas Chromatography

Toxic level: >20 mg/dL

Note: Refer to ARUP Consult’s Therapeutic Drug Monitoring topic for testing options.

Detect exposure to cannabinoids

THC Metabolite, Serum or Plasma, Quantitative 0090676

Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

May be useful in the assessment of exposure to synthetic cannabinoids up to several days after exposure

Synthetic Cannabinoid Metabolites, Qualitative, Urine 3000508

Method: Qualitative High Performance Liquid Chromatography-Tandem Mass Spectrometry

May be useful in the assessment of acute exposure to bath salts

For assessment several days after exposure, refer to Bath Salts Panel, Urine (2008650)

Bath Salts Panel, Serum or Plasma 2011411

Method: Quantitative High Performance Liquid Chromatography/Tandem Mass Spectrometry

May be useful in the assessment of exposure to bath salts up to several days after exposure

For assessment of acute exposure, Bath Salts Panel, Serum or Plasma (2011411) may be useful

Bath Salts Panel, Urine 2008650

Method: Quantitative High Performance Liquid Chromatography/Tandem Mass Spectrometry

Detect overdose exposure

Drug Screen (Nonforensic), Serum 0090499

Method: Semi-Quantitative Immunoassay/Gas Chromatography-Mass Spectrometry/ Liquid Chromatography-Tandem Mass Spectrometry

Useful when identity or class of the drug or drugs of interest is not known

Not recommended for assessment in routine compliance and/or abuse contexts

Drug Screen (Nonforensic), Urine, Qualitative 0090500

Method: Qualitative Immunoassay/Gas Chromatography-Mass Spectrometry/Liquid Chromatography-Tandem Mass Spectrometry

Monitor patient compliance

Drug Screen 9 Panel, Serum or Plasma - Immunoassay Screen with Reflex to Mass Spectrometry Confirmation/Quantitation 0092420

Method: Qualitative Enzyme-Linked Immunosorbent Assay/ Quantitative Gas Chromatography-Mass Spectrometry/Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Detect exposure

Flunitrazepam and Metabolites, Serum or Plasma, Screen with Reflex to Confirmation/Quantitation 0091116

Method: Quantitative High Performance Liquid Chromatography- Tandem Mass Spectrometry

Flunitrazepam and Metabolites, Urine Screen with Reflex to Confirmation/Quantitation 3000183

Method: Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry

Useful for general screening to assess drug abuse

Positive drug screen results are confirmed

Gamma-Hydroxybutyric Acid (GHB), Urine - Screen with Reflex to Confirmation/Quantitation 0091161

Method: Qualitative Gas Chromatography-Mass Spectrometry /Quantitative Gas Chromatography-Mass Spectrometry

Gamma-Hydroxybutyric Acid (GHB), Serum or Plasma - Screen with Reflex to Confirmation/Quantitation 0091193

Method: Qualitative Gas Chromatography-Mass Spectrometry /Quantitative Gas Chromatography-Mass Spectrometry

Monitor patient adherence and exposure

Ketamine and Metabolite Quantitative, Serum or Plasma 0091507

Method: Quantitative Gas Chromatography-Mass Spectrometry

Detect exposure

Cocaine Metabolite, Serum or Plasma, Quantitative 0090684

Method: Quantitative Gas Chromatography-Mass Spectrometry

Phencyclidine (PCP), Serum or Plasma, Quantitative 2010460

Method: Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry

Useful for general screening to assess drug abuse

Positive drug screen results are confirmed

Heroin - Screen with Reflex to Confirmation/Quantitation - Serum or Plasma 0091203

Method: Qualitative Enzyme-Linked Immunosorbent Assay/Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry

Monitor patient adherence

Propoxyphene and Metabolite, Serum or Plasma, Quantitative 2010464

Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Note: Also refer to ARUP Consult’s Pain and Addiction Management topic for testing options.

Aid in the assessment of acetaminophen toxicity

Acetaminophen 0090001

Method: Spectrophotometry

Critical toxic values:

Post 4-hr ingestion: >150 µg/mL
Post 12-hr ingestion: >40 µg/mL

Optimize drug therapy and monitor patient adherence

Ibuprofen Quantitative, Serum or Plasma 2014183

Method: Quantitative High Performance Liquid Chromatography/Tandem Mass Spectrometry

Aid in assessment of the etiology of anion gap acidosis

Refer to ARUP Consult topic Metabolic Acidosis for more information

Salicylate Assay 0090251

Method: Spectrophotometry

Toxic level: ≥31 mg/dL or greater

Note: Refer to ARUP Consult’s Therapeutic Drug Monitoring and Pain and Addiction Management topics for more testing options.

Useful for general screening in context of compliance and/or abuse

For follow-up testing of a presumptive result, Buprenorphine and Metabolites, Urine, Quantitative (2010092) is preferred

Buprenorphine, Urine Screen with Reflex to Quantitation 2012273

Method: Qualitative Enzyme Immunoassay/Quantitative Liquid Chromatography - Tandem Mass Spectometery

Useful for general screening in context of compliance and/or abuse

For follow-up testing of a presumptive result, Fentanyl and Metabolite, Urine Quantitative (0092570) is preferred

Fentanyl , Urine Screen with Reflex to Quantitation 2012284

Method: Qualitative Enzyme Immunoassay/Quantitative Liquid Chromatography - Tandem Mass Spectrometry

Useful for general screening in context of compliance and/or abuse

For follow-up testing of a presumptive result, Meperidine and Metabolite, Urine, Quantitative (3000248) is preferred

Meperidine, Urine Screen with Reflex to Quantitation 2012288

Method: Qualitative Enzyme Immunoassay/Quantitative Gas Chromatography-Mass Spectrometry

Preferred test to follow up presumptive results

For general screening, Opiates, Urine Screen with Reflex to Quantitation (2005093) is preferred

Opiates, Urine, Quantitative 0090364

Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Monitor patient adherence

For follow-up testing of a presumptive result, Opiates, Urine, Quantitative (0090364)

Oxycodone/Oxymorphone Screen Only, Urine 2005103

Method: Qualitative Enzyme Immunoassay

Useful for general screening in context of compliance and/or abuse

For follow-up testing of a presumptive result, Tapentadol and Metabolite, Urine, Quantitative (2003128) is preferred

Tapentadol Urine Screen with Reflex to Quantitation 2012294

Method: Qualitative Enzyme Immunoassay/Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Useful for general screening in context of compliance and/or abuse

For follow-up testing of a presumptive result, Tramadol and Metabolites, Urine, Quantitative (2002736) is preferred

Tramadol, Urine Screen with Reflex to Quantitation 2012297

Method: Qualitative Enzyme Immunoassay/Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Monitor cyanide exposure

Cyanide 0090060

Method: Quantitative Colorimetry

Toxic level: >100 µg/dL

Use to diagnose increased carbon monoxide levels and its poisoning

Carboxyhemoglobin Quantitation, Whole Blood by Co-Oximetry 2005757

Method: Spectrophotometry

Note: Refer to ARUP Consult’s Therapeutic Drug Monitoring topic for testing options.

Note: Refer to ARUP Consult’s Nicotine Exposure and Metabolites topic for more testing options.

Detect exposure

Amphetamines, Serum or Plasma, Quantitative 2010066

Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Cocaine Metabolite, Serum or Plasma, Quantitative 0090684

Method: Quantitative Gas Chromatography-Mass Spectrometry

Monitor patient adherence

Methylphenidate and Metabolite Quantitative, Serum or Plasma 3000253

Method: Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry

Use to detect and monitor nicotine, cotinine, and trans-3’-hydroxycotinine in serum or plasma

Serum or plasma testing may be useful when a valid urine specimen cannot be obtained (anuretic or dialysis)

Nicotine and Metabolites, Serum or Plasma, Quantitative 0092361

Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Note: Refer to ARUP Consult’s Trace Elements–Deficiency and Toxicity topic for testing options.

Medical Experts

Johnson-Davis, Kamisha, PhD, DABCC, FAACC, Medical Director, Clinical Toxicology at ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah

McMillin, Gwendolyn A., PhD, Medical Director, Toxicology, and Medical Director, Pharmacogenetics, at ARUP Laboratories; Professor of Clinical Pathology, University of Utah

References

Additional Resources

Dart RC, ed.. Medical Toxicology, 3rd. Philadelphia, PA: Lippincott Williams & Wilkins, 2003.

Ellenhorn M. Ellenhorn's Medical Toxicology: Diagnosis and Treatment of Human Poisoning, 2nd ed.. Philadelphia, PA: Williams & Wilkins, 1997.

Hoffman R, Howland M, Lewin N, Nelson L, Goldfrank L. Goldfrank's Toxicologic Emergencies, 10th. New York, NY: McGraw-Hill Education/Medical, 2014.

Wu A, McKay C, Broussard L, Hoffman R, Kwong T, Moyer T, Otten E, Welch S, Wax P. Emergency Toxicology, National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines. American Association for Clinical Chemistry. Washington, DC [Accessed: May 2019]

Resources from the ARUP Institute for Clinical and Experimental Pathology®

Taylor LL, Flint NA, Ma V, Hill BM, Clark CJ, Strathmann FG. Internal Hydrolysis Indicator for Sample Specific Monitoring of β-Glucuronidase Activity. J Anal Toxicol. 2017; 41(5): 407-411. PubMed

Wu F, Slawson MH, Johnson-Davis KL. Metabolic Patterns of Fentanyl, Meperidine, Methylphenidate, Tapentadol and Tramadol Observed in Urine, Serum or Plasma. J Anal Toxicol. 2017; 41(4): 289-299. PubMed

Content Review:

May 2019

Last Update: August 2019

Emergency Toxicology

Quick Answers

When should specimens be collected for emergency toxicology testing?

Which specimen is appropriate for emergency toxicology testing?

How should toxicology test results be interpreted?

Indications for Testing

Timing of Specimen Collection

Specimen Selection

Frequently Asked Questions

Additional Resources

ARUP Lab Tests

Alcohol Tests

Anticonvulsant/Antiepileptic Tests

Antidepressant Tests

Antipsychotic Tests

Cannabinoid Tests

Drug Detection Tests

Drug-Facilitated Sexual Assault Tests

Illicit Drug Tests

Nonopioid Pain Medication Tests

Opiate/Opioid Analgesic Tests

Other Toxicant Tests

Sedative-Hypnotics Tests

Stimulant Tests

Trace and Toxic Element Tests

Medical Experts

References

Additional Resources

Resources from the ARUP Institute for Clinical and Experimental Pathology®

ARUP Laboratories

ARUP Websites

ARUP Consult


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Emergency Toxicology

Quick Answers

When should specimens be collected for emergency toxicology testing?

Which specimen is appropriate for emergency toxicology testing?

How should toxicology test results be interpreted?

Indications for Testing

Timing of Specimen Collection

Specimen Selection

Frequently Asked Questions

Additional Resources

ARUP Lab Tests

Alcohol Tests

Anticonvulsant/Antiepileptic Tests

Antidepressant Tests

Antipsychotic Tests

Cannabinoid Tests

Drug Detection Tests

Drug-Facilitated Sexual Assault Tests

Illicit Drug Tests

Nonopioid Pain Medication Tests

Opiate/Opioid Analgesic Tests

Other Toxicant Tests

Sedative-Hypnotics Tests

Stimulant Tests

Trace and Toxic Element Tests

Medical Experts

References

Additional Resources

Resources from the ARUP Institute for Clinical and Experimental Pathology®

ARUP Laboratories

ARUP Websites

ARUP Consult