UDS: Universal Drug Screen?

Case Scenario: A 29 year-old man with a history of heroin abuse dies in respiratory failure due to a presumed heroin overdose, 6 hours after hospital admission despite resuscitative efforts including administration of multiple doses of naloxone. A UDS test is positive for benzodiazepines and negative for opiates and other illicit drugs of abuse. The death is reported and accepted by the local Medical Examiner (ME). Hospital admission blood and urine samples are additionally requested and conveyed to the ME’s Office. An autopsy is performed along with testing of the hospital admissions samples. The cause of death: Acute intoxication by the combined effects of fentanyl, acetylfentanyl, carfentanil, and alprazolam.

How comprehensive is your hospital lab’s Urine Drug Screen?  A myriad of obscure, clandestinely synthesized, highly potent, harmful, or rapidly fatal drug and medication analogues are not detected by standard urine drug screening tests used in many hospitals. These include fentanyl and fentanyl analogues, synthetic cathinones (“bath salts”), and synthetic marijuana (“K2”, “Spice”). Furthermore, hospital urine drug screening tests are limited by the parameters of the actual testing kit and report the presence (“positive”) or absence (“negative”) of the drug, medication, or drug/medication category included in the panel. Furthermore and for many reasons, a positive result does not always indicate an acute intoxication and a negative result does not exclude one either. Screen tests on blood (i.e. ELISA blood panel) are a better gauge for toxicity but again, only for what is included in the panel. It is important to recognize the limitations of urine drug screening in order to optimize management of the toxidromic patient. Would the patient in the above scenario have benefited from administration of additional doses of naloxone? Consultation with the hospital’s clinical pathologist or medical toxicologist who may recommend sample submission for testing at a more comprehensive reference laboratory, is optimal.

In contrast to hospital testing, postmortem forensic toxicology testing routinely involves comprehensive qualitative and quantitative testing of blood, urine, and other bodily fluids to aid the forensic pathologist in the determination of the cause, contributing factor(s), and the manner of many types of death. In addition to drug deaths, deaths resulting from motor vehicle accidents, falls, fires, over/under-medication, and homicidal and suicidal violence are included, often occurring after a period of hospitalization. In those instances, hospital admission blood and urine samples are particularly advantageous and will be requested if available. Intoxicants found in these samples would indicate a degree of intoxication closer to the actual time of intake and prior to infusion of resuscitative fluids, blood transfusions, metabolism, and the administration of medications. Under these conditions, intoxicants can become undetectable or otherwise uninterpretable due to the presence of low levels of parent drug and/or metabolites. Administration of medicines such as morphine and fentanyl during the terminal hospitalization can further confound interpretation and determination of the cause of death if based on results of testing of postmortem samples only.

 

More on this important topic can be found in Chapters 5 and 6 in Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner available on Amazon.com.

 

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You Have A Right NOT to Remain Silent!

Honesty is always the best policy- in death certification. This is particularly true as it applies to the certification of therapy-associated and peri-procedural deaths. While it may be tempting to mute or conceal the true cause of death out of concern for upsetting the family or of future litigation, it is better (and more defensible) to be objective and forthright.

Case Scenario 1:

A 45 year-old man with a history of schizophrenia stabilized on clozapine presents to the emergency department with a 2-day history of painful abdominal distention and absence of bowel movements. While awaiting diagnostic testing, he goes into cardiopulmonary arrest and dies despite resuscitative efforts. The death is reported to the local Medical Examiner who declines jurisdiction. A hospital autopsy is performed. Gross and microscopic examinations are diagnostic for toxic megacolon with perforation and acute peritonitis.

The cause of death is listed as “Cardiopulmonary arrest due to toxic megacolon”. (*Error alert!)

Case Scenario 2:

A 55 year-old man with a history of hypertension and atherosclerotic cardiovascular disease exsanguinates and arrests intra-operatively despite an emergent attempt to access and repair a spontaneously ruptured abdominal aortic aneurysm. Resuscitative efforts are unsuccessful. The death is reported to the local Medical Examiner who declines jurisdiction.  A hospital autopsy is performed.  The finding of massive hemoperitoneum and the rupture site of a 10.0 cm infra-renal aortic aneurysm confirms the source of the exsanguination, accompanied by severe complicated atherosclerosis seen grossly and microscopically.

The cause of death is listed as “Exsanguination”. (*Error alert!)

The monitoring of peri-procedural and therapy-associated deaths is an important facet in the maintenance of public health.  This includes the tracking of morbidity and mortality associated with medications, surgical procedures, and medical devices. MEDWATCH (www.fda.gov/medwatch) is “reporting central” for adverse events and deaths resulting from medical devices and medication errors in the United States. Therapy-associated and peri-procedural deaths are reportable and often accepted and certified by the Medical Examiner or Coroner particularly those that occur unexpectedly during or following diagnostic procedures or administration of medication, for the purposes of ruling out an alternate cause and manner of death. The manner-of-death classification for these deaths will be natural, therapeutic complication (a variant of natural), or accident. Homicide manner of death may be used in rare cases of deliberate administration (or withholding) of a medication. Rarely, the manner of death undetermined will be applied in inconclusive cases.

Deaths occurring in patients with extensive natural disease despite therapeutic interventions are certifiable by clinicians. Application of the “but for” rule is helpful in these instances: that but for the therapeutic/surgical intervention, the patient would have died from disease “X”. This rule is particularly applicable to emergent procedures performed for catastrophic natural disease such as in Scenario 2. Inclusion of the medication or procedure in the cause-of-death statement is necessary for ICD coding purposes, a tracking modality.

Case Scenario 1 may be certified as:

Part I.

 

 

A.  Acute peritonitis

 

Approximate interval: Onset to death

Hours

Due to (or as a consequence of):

B.  Spontaneous acute colonic perforation

 

Hours

 

Due to (or as a consequence of):

C. Toxic megacolon

 

2 days

 

Due to (or as a consequence of):

D. Complications of clozapine medication therapy for schizophrenia

 

Years

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I
 

Hypertensive cardiovascular disease

Manner of Death

Therapeutic Complication

(Natural)

 

 

 

 

And for Case Scenario 2:

Part I.

 

 

A. Exsanguination during emergency laparotomy

 

Approximate interval: Onset to death

 

Minutes

Due to (or as a consequence of):

B. Abdominal aortic aneurysm with spontaneous acute rupture

 

Hours

Due to (or as a consequence of):

C. Severe, complicated aortic atherosclerosis

 

Years

Due to (or as a consequence of):

D.

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I
Manner of Death

Natural

 

 

*Note the use of etiologic specific terminology and the avoidance of unnecessary, non-specific terms. Everyone eventually dies from cardiac and/or cardiopulmonary arrest. Exsanguination can be caused by diseases or trauma. Note also the inclusion of the word “spontaneous”, which distinguishes from a traumatic cause.

 

For more information on peri-procedural death certification and its relevance to public health surveillance, consult Chapters 2 and 8 in Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner.

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M.E. Does Not Stand for “Morgue Express”!

Why wasn’t an autopsy performed on my patient? -a not too infrequent question for the Medical Examiner or Coroner (ME/C). Contrary to popular belief of many in clinical practice, however, an autopsy will not be performed on every ME/C case.

Yearly, the cause and manner of death of approximately a half-million people is determined by medical examiners’ and coroners’ offices. But an autopsy will be performed on only a percentage of these in large part, to rule out (or rule in) that some type of acute injury, acute intoxication, or the sequela of injury or intoxication, actually caused or contributed to the death. Furthermore, it is beyond the capacity of many offices that are limited by staffing, infrastructure, budget, and the effects of the current opioid crisis, to perform an autopsy on every death. So in a death with a history of natural disease with lethal potential and no indications of foul play or trauma, a cause of death can be determined with the aid of an external-only examination of the body along with review of medical records and test results. Careful evaluation as to whether an autopsy is needed will be further applied to sudden infant and child deaths that include a natural disease history. Interpretation of postmortem testing is an added “tool in the toolbox” that is used. The cause of death can also be determined without an autopsy, in certain in-hospital deaths caused by accidental or suicidal trauma that have been well-documented clinically, where an autopsy likely would only confirm what was previously known clinically.

Well-staffed ME/C offices provide scientific and autopsy services for jurisdictional deaths. Those deaths are sudden, unexpected, unexplained, or that may have arisen under circumstances other that natural: by accident, suicide, or homicide. Identifying a homicidal death, with the aid of an autopsy, is of high priority as this will start or continue the turning of the “wheels of justice”. ME/C offices provide a public service, from a fund of ever-diminishing tax dollars.

 

Now, finally, the end to the 2-week, nail-biting suspense is near! The answers to the last PPQ follows.

  1. False. “MSOD due to sepsis” is an UN-acceptable cause-of-death statement. Two errors are represented: use abbreviations and use of non-specific clinical terminology ‘sepsis’ which does not specify the organism and the start of the chain of events that lead to the sepsis (i.e. sequela of trauma versus some natural disease entity)
  2. False. (the subject of this entry and the method to all this madness)
  3. A,B,C, and D. Yes, all of these deaths are reportable. A-death in custody. B-death within 24 hours of admission or the clinical definition of sudden death. C-if seizures can be linked to the remote head trauma, the manner of death will not be classified as natural. D-trauma-associated death or possibly therapy-associated.

Caveat for B: While this death is reportable to the ME/C, it is ABSOLUTELY a death that is certifiable by the pronouncing physician or the patient’s primary care physician who may be asked by the Medical Examiner or Coroner Investigator if he/she is willing to certify the death and complete the death certificate.

 

For more information on what “triage” means to the Medical Examiner of Coroner, consult Chapters 5 and 6 in Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner available on Amazon.com.

Or for a direct link, click https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408/ref=sr_1_1?ie=UTF8&qid=1

 

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