CHAPTER 25 Toxicologic Emergencies

Toxicologic emergencies include acute poisonings and intake of substances of abuse. These situations pose a unique challenge to the emergency department nurse. The American Association of Poison Control Centers annual report for 2004 stated that 92.7% of cases occurred in the home, with 51.3% occurring in children younger than 6 years and 38.5% involving children younger than 3 years of age. In addition, it was noted that 94% of toxic exposures were acute and 84.1% were unintentional. Therapeutic medication errors, such as double dosing or taking the wrong medication, accounted for more than 10% of all poisonings.¹ Ingestion or coingestion of over-the-counter (OTC) drugs such as antihistamines, antidiarrheals, or indigestion remedies in potential poisoning situations may cloud or mask true symptoms of acute poisoning. In 2004, nearly 1.3 million emergency department visits were associated with drugs of abuse or misuse, including prescription and OTC drugs, inhalants, and illicit drugs.² Patients may also use more than one drug in combination, with resulting polysubstance abuse, or may ingest a substance in combination with alcohol, thus leading to fatalities.

Consideration must be given to organic causes such as thyroid disease, hypoglycemia, hypoxia, or the purposeful or accidental exposure to a toxin or chemical when dealing with patients with an altered level of consciousness.

Treatment is directed toward preventing or decreasing absorption of the toxic substance (Table 25-1). This can be accomplished using measures to enhance elimination of the substance (Table 25-2) or by administering specific antidotes to counteract the toxic substance (Table 25-3).

Table 25-2 MEASURES TO ENHANCE ELIMINATION OF DRUGS OR CHEMICALS

Table 25-3 SPECIFIC ANTIDOTES

Data from Tintinalli, J. E., Kelen G. D. & Stapczynski J. S. (Eds.). (2003). Emergency medicine: A comprehensive study guide (6th ed.). New York: McGraw-Hill; Olson, K. (2004). Poisoning and drug overdose (4th ed.). East Norwalk, CT: Appleton & Lange; and Poisondex System (Internet database). Greenwood Village, CO: Thomson Micromedex. Available at www.thomsonhc.com. Updated periodically.

II. SPECIFIC TOXICOLOGIC EMERGENCIES

A. Alcohol Use

Alcohol is one of the most commonly used drugs in the United States. It is a component of roughly 70% of overdose cases in the emergency department. Alcoholism is a chronic illness characterized by impaired control over drinking that leads to physiologic, psychological, and/or social dysfunction. Alcohol affects all socioeconomic levels and slightly more male than female patients. It is metabolized in the liver and affects all body systems, including the central nervous system (CNS), gastrointestinal (GI), and cardiovascular systems. The development of subdural hematomas is not uncommon in patients with chronic alcoholism. Although alcohol initially causes a state of euphoria, it is actually a CNS depressant. Alcohol may be the primary drug of abuse or may be used concomitantly with other drugs. It is contained in beverages, perfumes, mouthwashes, and many OTC preparations (e.g., NyQuil).

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Symptoms may or may not be related to alcohol intoxication

b) Trauma from falls/head injury

c) Description of drinking episode: how much consumed, time, percentage of alcohol content

d) Tremors

e) Changes in level of consciousness

2) Past medical history

a) Current or preexisting diseases/illness

(1) Seizures/epilepsy

(2) Liver disease

(3) GI bleeding or varices

(4) Traumatic injury or recent fractures

(5) History of suicide gestures, anxiety, or depression

b) Concurrent medication use

(1) Prescription and/or OTC drug

(2) Lithium or disulfiram (Antabuse) use

(3) Seizure medications

c) Patterns of alcohol use/abuse

(1) Consumption pattern and type of alcohol

(2) Time since last drink

(3) Blackout history

(4) Change in tolerance

(5) Previous attempts to discontinue drinking, types of programs, duration of abstinence

3) Risk factors

a) Family history of alcoholism

b) Heavy drinking: more than five drinks in one sitting

c) Use of other drugs

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: disorientated to obtunded

(2) Decreased or elevated temperature

(3) Gait: staggering, ataxia

(4) Odors: alcohol, breath mints, mouthwash

(5) Hygiene: clean, well-groomed to disheveled

(6) Moderate to severe distress/discomfort

b) Inspection

(1) Nystagmus: intoxication

(2) Tremors, hallucinations, diaphoresis: withdrawal

(3) Spider angiomas

(4) Scars from previous falls

(5) Multiple bruises

(6) Recent or healing burns

(7) Gynecomastia

(8) Jaundice, icteric sclera

c) Palpation

(1) Abdominal tenderness, ascites

(2) Hepatomegaly

2) Diagnostic procedures

a) Serum blood alcohol level and/or Breathalyzer

b) CBC with differential

c) Serum chemistries including glucose

d) Serum and urine toxicology screens

e) LFTs

f) Coagulation profile

g) Urinalysis; pregnancy test in female patients of childbearing age

h) Cervical spine radiograph

i) Chest radiograph

j) Head CT scan and/or MRI

k) ECG

2. Analysis: differential nursing diagnoses/collaborative problems

a. Acute/chronic confusion

b. Disturbed sensory perception

c. Risk for poisoning

d. Risk for injury

e. Risk for ineffective airway clearance

f. Risk for deficient fluid volume

g. Risk for decreased cardiac output

h. Dysfunctional family processes due to alcoholism

i. Risk for self/other-directed violence

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (see Chapter 1)

1) Provide supplemental oxygen as indicated

a) Rapid-sequence intubation (RSI) and ventilatory support in obtunded patients

b) High-flow oxygen

b. Establish IV access for administration of crystalloid fluids/medications

c. Prepare for/assist with medical interventions

1) Advanced airway management

a) Nasal or oral intubation

b) Laryngeal mask airway

c) Combitube

d) Surgical airway (e.g., cricothyrotomy)

2) Institute cardiac and pulse oximetry monitoring

3) Minimize stimulation to decrease sensory alteration

a) Use quiet environment

b) Keep lights on to decrease shadows and visual hallucinations

4) Minimize behavior escalation to decrease violence potential

a) Decrease stimulation and noise as needed

b) Closely monitor patient behavior to prevent escalation

c) Use restraints per institutional protocols: chemical, soft, leather

5) Prevent injury

a) Limit patient ambulation to prevent falls

b) Initiate seizure precautions per institutional protocols

c) Encourage behaviors that prevent self-harm or harm to others

6) Insert gastric tube as indicated

a) Gastric lavage: controversial and potentially useful only if performed within 1 to 4 hours after ingestion

7) Insert indwelling urinary catheter as indicated

8) Assist with possible hospital admission

d. Administer pharmacologic therapy as ordered

1) RSI premedications: sedatives, analgesics, neuromuscular blocking agents

2) Dextrose 50% (D50W) if patient is hypoglycemic

3) Thiamine and multivitamins to combat Wernicke-Korsakoff syndrome and malnutrition

4) Replace depleted electrolytes as needed: potassium, magnesium

5) Benzodiazepines: chlordiazepoxide hydrochloride (Librium), lorazepam (Ativan), diazepam (Valium) for agitation and seizures resulting from overdose or withdrawal

6) Antipsychotics: haloperidol (Haldol) for delirium and agitation

e. Educate patient and significant others

1) Initiate social service consultation or psychiatric evaluation as needed

2) Review discharge medications with patient and family

3) Refer, and encourage participation in process, to Alcoholics Anonymous/other support group as appropriate

4) Encourage consistent primary care follow-up to encourage sobriety

4. Evaluation and ongoing monitoring (see Appendix B)

a. Airway patency

b. Level of consciousness

c. Hemodynamic status

d. Seizure activity

e. Breath sounds and pulse oximetry

f. Cardiac rate and rhythm

g. Intake and output

h. Ambulation ability

i. Continued presence or absence of hallucinations

j. Drug levels

B. Opiate Use

Opiates are narcotics, substances derived from the opium poppy. These include morphine sulfate, heroin, and semisynthetic derivatives such as hydrocodone, oxycodone, propoxyphene (Darvon), tramadol (Ultram), and fentanyl (Sublimaze). Opiates are prescribed to decrease severe pain. They blunt the perception of pain and are also used for preoperative sedation and as a supplement to anesthesia. Opiates usually produce brief euphoria followed by a pleasant, dreamlike state. It is not uncommon to see polydrug use to potentiate and increase the duration of action. Frequent use of opioids may lead to dependence, addiction, and tolerance. Death occurs from the side effects of the drugs, most notably respiratory arrest and pulmonary edema.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Substance ingested and amount

b) Route of ingestion: oral, IV, nasal inhalation, smoked, skin-popping

c) Time of ingestion: short-term versus long-term use, tolerance

d) Polysubstance abuse, including chemicals used to “cut” the drug or dilute it (e.g., quinine, sugar, starch) and other drugs to potentiate its effects

e) Symptoms: classic triad of pinpoint pupils, decreased respirations, and coma

(1) Decreased consciousness/coma

(2) Respiratory depression/arrest: slow, deep respirations of three to four per minute

(3) Seizures (associated with meperidine, propoxyphene, tramadol)

(4) Nausea/vomiting, constipation

2) Past medical history

a) Current or preexisting diseases/illness

(1) HIV infection or AIDS

(2) Hepatitis

(3) Endocarditis

(4) Tuberculosis

b) Suicidal ideation/gesture

c) Detoxification history

d) Medications

e) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: apathy, drowsiness, lethargy, seizures

(2) Respiratory: apnea or arrest

(3) Hypotension, bradycardia

(4) Moderate to severe distress/discomfort

b) Inspection

(1) Pupils: pinpoint pupils (miosis) are hallmark of narcotic abuse

(2) Skin: track marks, lesions secondary to skin-popping, abscesses, cyanosis

c) Auscultation

(1) Breath sounds: crackles

2) Diagnostic procedures

a) Serum and urine toxicology screen

b) Urinalysis: pregnancy test in female patients of childbearing age

c) ABGs

d) Chest radiograph

2. Analysis: differential nursing diagnoses/collaborative problems

a. Risk for ineffective airway clearance

b. Impaired gas exchange

c. Ineffective breathing pattern

d. Risk for poisoning

e. Risk for ineffective coping, hopelessness, suicide

f. Risk for self/other-directed violence

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen as indicated

1) Bag-mask ventilation if respiratory depression or arrest

c. Establish IV access for administration of crystalloid fluid/medications

d. Prepare for/assist with medical interventions

1) Institute cardiac and pulse oximetry monitoring

2) Insert gastric tube as indicated

a) Gastric lavage: controversial and potentially useful only if performed within 1 hour after ingestion

e. Administer pharmacologic therapy as ordered

1) Naloxone (Narcan): short-acting narcotic antagonist

a) Actions: opioid antagonist and will precipitate withdrawal

b) Administer by the IV or intramuscular route; may need to repeat doses, especially with propoxyphene, secondary to its short length of action

c) Consider repeated naloxone therapy before disposition

d) Children and neonates should receive naloxone if suspected overdose or maternal addiction

2) Activated charcoal with or without cathartic

f. Educate patient and significant others

1) Refer to support services or Narcotics Anonymous

2) Provide information on detoxification procedures

4. Evaluation and ongoing monitoring

a. Airway patency

b. Level of consciousness

c. Hemodynamic status

d. Breath sounds and pulse oximetry

e. Cardiac rate and rhythm

f. Seizure activity

C. Cocaine Use

Cocaine is one of the most popular drugs of abuse. “Snorting” or intranasal use is the most common route of administration; however, it can be smoked or injected. “Crack,” “Rocks,” or free-based smokeable cocaine is more purified, it gives the user a “rush” similar to IV use, and it has a higher addiction potential. Cocaine stimulates the CNS and autonomic nervous system to increase the release of catecholamines from the adrenergic nerve terminals. It blocks the reuptake of dopamine and norepinephrine, thereby resulting in increased motor activity, insomnia, and euphoria. Patients seen in the emergency department for cocaine use are there predominantly for management of secondary complications. Treatment is aimed at supportive corrective measures. Medicinally, cocaine is used as an anesthetic and a vasoconstrictor in nasal surgery.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Route of ingestion

b) Time of ingestion: cocaine’s effects are short lived compared with those of other amphetamines

c) Polysubstance abuse: alcohol, downers (sedatives), or speedballs (heroin and cocaine combination) to potentiate its effects

d) Body packing: ingestion of large amounts of cocaine-filled balloons/condoms to avoid law enforcement detection

e) Symptoms

(1) Mood changes: euphoria, decreased fatigue, increased energy, agitation, aggression

(2) Cardiac: palpitations, chest pain, angina

(3) Pupils: dilated pupils are hallmark

(4) Seizures

(5) Other: restless, jittery, anxious, weight loss, drug craving for more cocaine, tactile hallucinations such as “cocaine bugs” (feeling insects crawling under skin) with long-term use

2) Past medical history

a) Current or preexisting diseases/illness

(1) Cardiovascular disease

(2) Stroke, seizures

b) Psychiatric history: suicidal ideation, substance use/abuse history

c) Antibody status: HIV infection, hepatitis, tuberculosis

d) Family history of substance use/abuse

e) Last normal menstrual period: female patients of childbearing age because cocaine causes increased incidence of spontaneous abortions

f) Medications

g) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: may range from hypomania to euphoria to depression

(2) Seizure activity

(3) Hypertension, tachycardia, hyperthermia

(4) Moderate to severe distress/discomfort

b) Inspection

(1) Pupillary response: mydriasis, photophobia

(2) Perforated nasal septum from snorting

(3) Skin infections/abscesses

c) Auscultation

(1) Breath sounds: crackles, rhonchi

(2) Heart sounds: rubs, murmurs

2) Diagnostic procedures

a) Serum and urine toxicology screen

b) Urinalysis: myoglobin; pregnancy test in female patients of childbearing age

c) Chest radiograph

d) Head CT scan/MRI: intracranial hemorrhage, cerebrovascular accident (CVA)

e) ECG

f) Echocardiogram

2. Analysis: differential nursing diagnoses/collaborative problems

a. Impaired gas exchange

b. Impaired tissue perfusion

c. Decreased cardiac output

d. Hopelessness

e. Risk for suicide

f. Risk for self/other-directed violence

g. Ineffective coping

h. Risk for poisoning or injury

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen as indicated

c. Establish IV access for administration of crystalloid fluid/medications

d. Prepare for/assist with medical interventions

1) Institute cardiac and pulse oximetry monitoring

2) Insert gastric tube as indicated

a) Whole bowel irrigation through a gastric tube may be indicated for body packers

e. Administer pharmacologic therapy as ordered

1) Haloperidol (Haldol) for delirium or psychosis

2) Activated charcoal may be administered prior to whole bowel irrigation

3) Whole bowel irrigation with a polyethylene glycol and electrolyte solution such as GoLYTELY may be indicated

f. Educate patient and significant others

1) Knowledge of effects of cocaine on body

2) Cocaine addiction/dependence

3) Refer to support services or Narcotics Anonymous

4) Provide information on detoxification procedures

4. Evaluation and ongoing monitoring (see Appendix B)

a. Hemodynamic status

b. Cardiac rate and rhythm

D. Amphetamine Use

Amphetamines are synthetic sympathomimetic drugs that stimulate the CNS and produce a feeling of excess energy. They are commonly used to suppress appetite, elevate mood, stay awake, and control symptoms of attention-deficit disorder. Amphetamines are available in oral, intranasal, or parenteral forms. Crystalline rock forms such as “ice” are smoked. “Body packers” are seen in the emergency department as a result of swallowing packages, condoms, or rocks while either transporting the drugs or evading police pursuit. Common amphetamines include crystal methamphetamine, dextroamphetamine, and methylphenidate (Ritalin). Recently, fenfluramine (Redux), the weight reduction medication, was withdrawn from the market because of its side effects, which included pulmonary hypertension and valvular heart disease.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Type of drug ingested

b) Route: oral, smoked, snorted, IV, body packing

c) Time of ingestion and quantity: if a body pack ruptures, a large quantity will be absorbed internally at one time

d) Reason for use: suicidal, recreational, intentional, weight loss

e) Presenting symptoms: same as cocaine but longer duration

2) Past medical history

a) Current or preexisting diseases/illness

(1) Obesity

(2) Attention-deficit disorder

(3) Hyperactivity

(4) Narcolepsy

(5) Psychiatric

b) Previous substance use/abuse

c) Medications

d) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: anxious, restless, paranoia/delusions, seizure activity

(2) Hygiene: possibly unkempt

(3) Hypertension, tachycardia, hyperthermia

(4) Moderate distress/discomfort

b) Inspection

(1) Pupillary response: mydriasis

(2) Tremors

(3) Thin, emaciated appearing

(4) Skin lesions related to formication (type of paresthesia from sensation of ants/insects running on skin)

c) Auscultation

(1) Heart sounds: murmurs

2) Diagnostic procedures

a) Serum and urine toxicology screen

b) Urinalysis; pregnancy test in female patients of childbearing age

c) Abdominal radiograph: assess body packing

d) ECG

e) Echocardiogram: fenfluramine users

2. Analysis: differential nursing diagnoses/collaborative problems

a. Decreased cardiac output

b. Risk for poisoning

c. Risk for hyperthermia

d. Ineffective coping, hopelessness

e. Risk for suicide and/or self/other-directed violence

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen as indicated

c. Establish IV access for administration of crystalloid fluid/medications

d. Prepare for/assist with medical interventions

1) Institute cardiac and pulse oximetry monitoring

2) Insert gastric tube as indicated

a) Gastric lavage; controversial and potentially useful only if immediate life-threatening intoxication; emesis contraindicated because of potential for aspiration

b) Whole bowel irrigation through a gastric tube may be indicated with body packers

3) Maintain normothermic body temperature: cooling measures for hyperthermia

4) Decrease risk for violence; protect patient and staff

a) Decrease sensory stimulation by placing patient in a quiet area

b) Use consistent, nonjudgmental caregivers, and set appropriate limits on behavior

c) If other measures fail, consider restraints to prevent staff and patient injury: soft, leather, or chemical per policy and procedures

e. Administer pharmacologic therapy as ordered

1) Activated charcoal: prevents systemic absorption

2) Benzodiazepines: provides sedation

3) Haloperidol (Haldol): for psychotic symptoms

4) Whole bowel irrigation with polyethylene glycol and electrolyte solution such as GoLYTELY for body packers

f. Educate patient and significant others

1) Refer patient/family to detoxification center and/or to support services

2) Effects of amphetamines on body

4. Evaluation and ongoing monitoring (see Appendix B)

a. Hemodynamic status

b. Cardiac rate and rhythm

c. Seizure activity

d. Intake and output

e. Core temperature

f. Continued presence or absence of hallucinations or agitation

E. Lysergic Acid Diethylamide Use

Psychedelic drugs such as lysergic acid diethylamide (LSD) cause changes in thought, mood, perception, and consciousness. The hallucinogenic effects last 6 to 12 hours and may include visual illusions and alteration in both sound and color intensity. LSD is known to flood the user with stimuli. LSD is colorless, odorless, and tasteless and comes in liquid or tablet form. It may also be absorbed through the skin. Initial symptoms are sympathomimetic: tachycardia, tachypnea, and the “fight-or-flight” response. LSD may be “laced” with phencyclidine (PCP), strychnine, or cocaine. Unlike most substances, LSD has no withdrawal syndrome, nor does it cause physical dependence.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Route of ingestion

b) Time of use

c) Reason for use: accidental, recreational

d) Substance used to “lace” or mix with the drug

e) Polysubstance use

f) Symptoms

(1) Paranoia

(2) Hallucinations, especially visual changes such as intense colors, perception of flowing objects

(3) Mood changes: poor judgment, short attention span

2) Past medical history

a) Current or preexisting diseases/illness

(1) Psychiatric history

b) Previous LSD use

c) Medications

d) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: ranges from euphoria to fear, anxiety and panic, hallucinations, paranoia, psychosis

(2) Tachycardia, hypertension, hyperthermia

(3) Moderate to severe distress/discomfort

b) Inspection

(1) Pupil response: dilation (mydriasis)

2) Diagnostic procedures

a) Serum and urine toxicology screen

b) Urinalysis; pregnancy test in female patients of childbearing age

2. Analysis: differential nursing diagnoses/collaborative problems

a. Acute/chronic confusion

b. Disturbed sensory perception

c. Risk for injury or self/other-directed violence

d. Anxiety/fear

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen as indicated

c. Establish IV access for administration of crystalloid fluid/medications

d. Prepare for/assist with medical interventions

1) Minimize sensory-perceptual alteration

a) Reinforce to patient that effects of drug are time limited

b) Assist patient in separating hallucinations from real-life events

c) Reduce sensory stimulation

2) Decrease risk for violence; protect patient and staff

a) Attempt to de-escalate an agitated and anxious patient

b) Maintain calm, nonjudgmental attitude and offer reassurance

c) Consider use of soft, leather, or chemical restraints, per institutional protocols, if all measures to provide patient and staff safety fail

e. Administer pharmacologic therapy as ordered

1) Benzodiazepines: agitation

2) Haloperidol (Haldol): psychosis

4. Evaluation and ongoing monitoring (see Appendix B)

a. Hemodynamic status

b. Continued presence or absence of hallucinations

F. Phencyclidine Use

Phencyclidine (PCP) is a widely used street drug known as a dissociative anesthetic that decreases awareness of one’s surroundings. PCP has characteristics similar to those of ketamine and was initially used as a surgical anesthetic in veterinary and human medicine. PCP use was discontinued when patients experienced terrifying emergence reactions, such as delusions and paranoia, when the drug’s effects diminished. PCP is consumed by dusting it on a cigarette and smoking it, taking it in pill form, snorting it, or absorbing it through skin contact. It is rapidly absorbed in the bloodstream, quickly distributed to tissues, and is highly lipophilic. PCP affects the CNS and causes stimulation or depression, as well as cholinergic-like effects, including muscular rigidity, thought disorganization, and violent, agitated behavior. Common street names include angel dust, Cadillac, CJ, killer weed, magic mist, and cyclones. Acute complications resulting from the increased muscle rigidity include rhabdomyolysis and renal failure. Other complications include respiratory depression, apnea, cerebral hemorrhage, and psychosis.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Route of exposure

b) Circumstances of use: accidental versus recreational deliberate use

c) Concomitant drug use

d) Symptoms

(1) Violent combative behavior, increased strength, lack of pain sensation

(2) Pupil changes: bidirectional nystagmus in an awake patient is classic; pinpoint pupils (miosis)

(3) Tremors/increased strength: “superhuman” strength as result of decreased pain feedback mechanism

(4) Nausea, vomiting, abdominal pain

2) Past medical history

a) Current or preexisting diseases/illness

(1) HIV infection

(2) Psychiatric history

(3) Hepatitis

(4) Tuberculosis

b) Previous PCP use

c) History of recent trauma: death usually occurs from associated trauma/injury

d) Medications

e) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: varies from drowsiness to irritability, euphoria and extreme agitation, bizarre or combative behavior, paranoia, seizure activity

(2) Tachycardia, hypertension

(3) Gait: altered, ataxia

(4) Moderate to severe distress/discomfort

b) Inspection

(1) Nystagmus: bidirectional (horizontal, vertical, rotary)

(2) Tremors and hyperactivity

(3) Myoclonus

(4) Drooling

c) Palpation

(1) Anesthesia to painful stimuli

2) Diagnostic procedures

a) Serum and urine for toxicology screen

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