Rapid point-of-care identification of oral medications in gastric lavage content by ambient mass spectrometry in the emergency room.

RATIONALE: Acute poisoning should be handled with high efficiency in order to minimize morbidity and mortality in the emergency room. Unfortunately, history-taking and physical examination are not always reliable. Mis-swallowing of oral medications is common in the pediatric group. This study aimed at developing a rapid point-of-care ambient mass spectrometric method for the early identification of ingested oral medications in gastric lavage content. METHODS: Four different types of oral medications that are most commonly mis-swallowed by children were diluted to different concentrations. Each of these chemical solutions was mixed with human gastric lavage content. A direct metallic sampling probe was dipped into the solution. It was then inserted promptly into the thermal desorption electrospray ionization source to carry out ionization and subsequent mass spectrometric analysis of the medications. The corresponding compounds were identified through matching of the obtained mass spectrometric data with those provided by well-established databases. RESULTS: Since no pretreatment of the specimen was required, the sampling step, and the subsequent thermal desorption electrospray ionization and mass spectrometric detection of the medications were completed within 30 s. Mass spectra were obtained for four different kinds of oral medication. The limit-of-detection of the four tested oral medications in gastric lavage content is at sub-ppm level, which is sensitive enough for emergency medicine applications since the quantities of medications ingested by pediatric patients are usually much higher. CONCLUSIONS: Thermal desorption electrospray ionization mass spectrometry, with informational support provided by an online mass spectral database, allows for early point-of-care identification of mis-swallowed oral medications in the evacuated gastric lavage contents obtained from gastric lavage of patients in the emergency room, and it is promising in providing important toxicological information to ensure the appropriateness of the subsequent medical management. Copyright © 2016 John Wiley & Sons, Ltd.

Test sequence in the management of gastrointestinal bleeding.

BACKGROUND AND STUDY AIM: A large variety of test procedures is available to diagnose and treat patients with suspected gastrointestinal bleeding. The aim of the study was to investigate which test sequence should be utilized in managing gastrointestinal bleeding. METHODS: For each endoscopic, radiologic, or laboratory test procedure, professional fees and facility costs were estimated based on payments allowed by the US Centers for Medicare and Medicaid Services during the fiscal year 2010. A threshold analysis was used to compare the costs associated with different test sequences of varying clinical scenarios. RESULTS: A threshold represents the lowest expected probability of success, for which a test would still be indicated. In a work-up including all possible management options, the threshold associated with laboratory tests and gastric lavage was 1 %, esophagogastroduodenoscopy (EGD) 8 %, colonoscopy 9 %, nuclear scan 9 %, enteroscopy 11 %, computed tomography (CT) angiography 14 %, capsule endoscopy 23 %, and angiography with transcatheter embolization 25 %. Varying sets of thresholds were calculated for different clinical scenarios. The thresholds of EGD and colonoscopy remained low in most scenarios. In sensitivity analysis, rising risk of complications or costs of a procedure also lead to rising threshold values for it, potentially rendering the particular procedure untenable. CONCLUSIONS: A low threshold indicated a preferred management option that should be used early rather than late in a sequence of multiple possible test procedures to work up instances of gastrointestinal bleeding.