Heroin Toxicity Workup

  • Author: Rania Habal, MD; Chief Editor: Michael R Pinsky, MD, CM, FCCP, FCCM   more...
 
Updated: Apr 15, 2011
 

Laboratory Studies

  • The diagnosis of heroin poisoning is usually made clinically, and laboratory analysis does not alter therapy in the emergent setting. Additional tests and further workup are indicated if the patient's condition does not respond to naloxone or if the patient's course of treatment is complicated.
  • Qualitative analysis may be helpful in confirming heroin use, as well as concomitant use of other drugs. Co-ingestion of alcohol, benzodiazepines, cocaine, and amphetamines is common and may contribute to morbidity and mortality. Therapeutic drug levels should be obtained if the patient is taking prescription narcotics, as these drug levels commonly contain acetaminophen or aspirin.
  • Heroin is quickly metabolized to 6-MAM and morphine. Most qualitative toxicologic studies screen for morphine only and use the presence of morphine in the urine as a surrogate for heroin use. In criminal and legal cases, however, testing for specific compounds is necessary, and, because 6-MAM can be generated only from heroin metabolism, the presence of 6-MAM on a drug screen is taken as evidence for heroin use.
  • Arterial blood gas analysis: In mild-to-moderate heroin overdoses, arterial blood gas (ABG) analysis reveals respiratory acidosis. In more severe overdoses, tissue hypoxia is common, leading to mixed respiratory and metabolic acidosis. The presence of unexplained metabolic acidosis should prompt a search for a co-ingestion or contamination with poisonous substances such as cyanide and clenbuterol.
  • Metabolic panel: Hypoglycemia must be diagnosed at the bedside and treated immediately. A complete metabolic panel is indicated if the patient's coma persists despite the infusion of naloxone (Narcan), dextrose, and thiamine (the coma protocol).
  • Liver function tests (LFTs) and coagulation studies are indicated if hepatitis is suspected and can determine ammonia levels if hepatic encephalopathy is suspected.
  • Renal function tests: Renal function should be monitored in patients with rhabdomyolysis, shock, or prolonged coma and in the setting of sepsis, severe hypertension (HTN), and preexisting renal insufficiency.
  • Complete blood cell (CBC) count: A CBC count is indicated if infection, blood loss, or immunodeficiency is suspected.
  • Creatine kinase (CK): Determination of the CK level is indicated when rhabdomyolysis or compartment syndrome is suspected. An elevated CK level may denote cardiac injury in comatose patients.
  • A pregnancy test should be considered in women of childbearing age.
  • Cerebrospinal fluid (CSF) analysis is indicated when an infectious process is suspected.
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Imaging Studies

  • Chest radiography: Chest radiography is indicated if the patient remains hypoxic. A chest radiograph may help diagnose many of the pulmonary complications of heroin poisoning, including noncardiogenic pulmonary edema (NCPE) (depicted in the radiograph below), aspiration pneumonitis, atelectasis, and other complications of drug use such as pneumothorax, pneumomediastinum, pneumoperitoneum, septic pulmonary emboli, fungal infections, and aspiration pneumonia. Adulterants may also cause pulmonary abnormalities. Talc, for example, causes granulomatosis and thrombosis of small pulmonary vessels and may appear as a reticulonodular pattern. Long-term talc exposure may also result in pulmonary hypertension. Heroin-related noncardiogenic pulmonary edema. Heroin-related noncardiogenic pulmonary edema.
  • Abdominal radiography: Abdominal radiographs are helpful in demonstrating the presence of radiopaque substances in the GI tract, as well as vials or bags of heroin.
  • Computerized tomography (CT) scan: CT scan of the brain is indicated in the presence of focal neurologic findings or when coma persists. A CT scan may reveal space-occupying lesions such as brain abscesses, intracerebral or extracerebral hematomas, and stroke.
  • Magnetic resonance imaging (MRI): MRI of the brain is helpful in establishing the diagnosis of heroin-induced leukoencephalopathy. Findings include white-matter abnormalities in the cerebellum and posterior limb of the internal capsule.
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Other Tests

  • Electrocardiogram: An electrocardiogram (ECG) may show abnormalities in rhythm and rate, which are rare in pure opioid overdoses but common to some co-ingestants and adulterants of street drugs. An ECG may also reveal evidence of myocardial ischemia.
  • Echocardiography (ECHO): An ECHO is indicated if endocarditis is suspected. An ECHO may also help diagnose acute pulmonary hypertension secondary to embolic disease.
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Procedures

  • Endotracheal intubation: Endotracheal intubation is indicated for airway protection and may be required in the management of hypoxia due to NCPE. Endotracheal intubation with ventilation may also be required in the management of increased intracranial pressure and shock.
  • Pulmonary artery catheterization: NCPE secondary to opioid overdose is characterized by a normal pulmonary capillary wedge pressure and mildly increased pulmonary arterial pressure.
  • Lumbar puncture: In the absence of signs of increased intracranial pressure, a lumbar puncture is indicated in comatose patients who have evidence of meningitis or fever without a source. In cases in which bacterial meningitis is suspected, antibiotic therapy should not be delayed by the lumbar puncture.
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Contributor Information and Disclosures
Author

Rania Habal, MD  Assistant Professor, Department of Emergency Medicine, New York Medical College

Disclosure: Nothing to disclose.

Specialty Editor Board

Laurie Robin Grier, MD  Medical Director of MICU, Professor of Medicine, Department of Emergency Medicine, Anesthesiology and OBGYN, Section of Pulmonary and Critical Care Medicine, Louisiana State University Health Science Center at Shreveport

Laurie Robin Grier, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Society for Parenteral and Enteral Nutrition, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Daniel R Ouellette, MD, FCCP  Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Pulmonary Disease and Critical Care Medicine Service, Henry Ford Health System

Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society

Disclosure: Boehringer Ingleheim Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Astra Zeneca Honoraria Speaking and teaching

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, FCCP, FCCM  Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, Vice-Chair of Academic Affairs, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center

Michael R Pinsky, MD, CM, FCCP, FCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, European Society of Intensive Care Medicine, Shock Society, and Society of Critical Care Medicine

Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

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Heroin-related noncardiogenic pulmonary edema.
Track marks in a heroin intravenous drug user.
Necrotizing fasciitis in a heroin user.
Endocarditis-related septic pulmonary emboli in a heroin user.
 
 
 
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