Synthetic Cannabinoid Use - Medical Records Abstraction

Form Approved;

OMB No. 0920-1011;

Exp Date: 3/31/2017

Adverse Health Effects Associated with
Synthetic Cannabinoid Use — Mississippi, 2015

medical records review

Reviewer/Interviewer:______________________Agency:________________Abstraction Date:(mm/dd/yy):____________

Emergency Department (ED):________________________, or Coroner/Medical Examiner Name___________________

pATIENT identification
Full Name (Last Name, First Name)			Medical Record Number
Date of Birth (mm/dd/yy)	Age			Sex
Address
City/State/Zip
Phone/Home If not recorded, please enter 000-000-0000		Phone/Cell If not recorded, please enter 000-000-0000

Medical records abstraction

Type of Records reviewed (mark all that apply): ☐ Emergency Medical Services (EMS)/Ambulance notes* ☐ Emergency Department notes ☐ Police documentation ☐ Medical Toxicologist consultation notes

☐ Admission History and Physical** ☐ Discharge Summary ☐ Coroner/Medical Examiner Documentation*** ☐ Other _____________________

*If patient not brought in or seen by EMS, skip to Section B. **If patient was admitted also complete Section C ***If patient is deceased also complete Section D.

A. Prehospital Data (from EMS Records or ED Records)

Date and (approximate) Time of Presentation to EMS (mm/dd/yy, hh:mm AM/PM): _________________ ☐ Not Recorded

Chief Complaint/ History (record narrative details, and indicate source(s) of information e.g. patient, friend/family, police, etc.)

Initial EMS Vital Signs Date:_____________(mm/dd/yy) Time:___________(hh:mm AM/PM) Temperature ______°(specify F or C) ☐ Not Recorded Heart Rate:______/minute Blood Pressure:_____/_____ Respiratory Rate:______/minute Oxygen Saturation: ______% Was the patient on supplemental oxygen? ☐ Yes ☐ No ☐ Unknown

Specific Mental Status Descriptors at Time of EMS Presentation (mark all that apply, including those in chief complaint): ☐ Confused ☐ Disoriented ☐ Delirious ☐ Anxious ☐ Tremulous ☐ Agitated ☐ Hallucinating ☐ Paranoid ☐ Psychotic ☐ Seizures ☐ Aggressive/Violent ☐ Hyperalert/Hypervigilant ☐ Unable to speak ☐ Somnolent ☐ Unresponsive ☐ Comatose ☐ Other________________________ ☐ WNL ☐ Unknown

Interventions ☐ Yes ☐ No If yes, mark all that apply: ☐ Intubation, specify reason (e.g. hypoventilation, airway protection) ______________________ Date and Time ______________ ☐ Cardiopulmonary resuscitation ☐ Other(s) __________________________________

Medications ☐ Yes ☐ No If yes, mark all that apply: ☐ Benzodiazepine (e.g. Ativan, Versed, Valium) Name:________________ Dose:___________ Time of Administration____________ Name:________________ Dose:___________ Time of Administration____________ ☐ Antipsychotics (e.g. Haldol, Geodon) Name:________________ Dose:___________ Time of Administration____________ Name:________________ Dose:___________ Time of Administration____________ ☐ Dissociative Anesthetics (e.g. Ketamine, Propofol) Name:________________ Dose:___________ Time of Administration____________ Name:________________ Dose:___________ Time of Administration____________ ☐ Antidotes (e.g. Glucose, Narcan, Physostigmine, Flumazenil) Name:________________ Dose:___________ Time of Administration____________ Name:________________ Dose:___________ Time of Administration____________ ☐ Other Name:________________ Dose:___________ Time of Administration____________ Name:________________ Dose:___________ Time of Administration____________ Name:________________ Dose:___________ Time of Administration____________ Name:________________ Dose:___________ Time of Administration____________

NB. If abstraction ends at this point, please go to last page to complete lab testing tier

B. ED Record Review

Mode of Presentation to ED: ☐ Self/Ambulatory ☐ Friends/Family ☐ Ambulance ☐ Police ☐ Other ___________________

Date and (approximate) Time of Presentation to ED (mm/dd/yy, hh:mm AM/PM):___________________☐ Not Recorded

Chief Complaint/History (record pertinent narrative details, and indicate source(s) of information e.g. patient, friend/family, police, EMS personnel, etc):

Initial ED Vital Signs: Date:__________(mm/dd/yy) Time:__________ (hh:mm AM/PM) Temperature ______°(specify F or C); Heart Rate:______/minute; Blood Pressure:_____/_____ Respiratory Rate:______/minute Oxygen saturation:______% Was the patient on supplemental oxygen? ☐ Yes ☐ No ☐ Unknown

Specific Mental Status Descriptors at Time of Presentation (mark all that apply): ☐ Confused ☐ Disoriented ☐ Delirious ☐ Anxious ☐ Tremulous ☐ Agitated ☐ Hallucinating ☐ Paranoid ☐ Psychotic ☐ Seizures ☐ Aggressive/Violent ☐ Hyperalert/Hypervigilant ☐ Unable to speak ☐ Somnolent ☐ Unresponsive ☐ Comatose ☐ Other__________________☐ WNL ☐ Unknown

Physical Exam Findings/Descriptors at Time of Presentation (mark all that apply):

Skin: ☐ WNL ☐ Diaphoretic (sweating) ☐ Flushed ☐ Dry ☐ Other_________ ☐ Unknown ☐ Abrasions/ wounds If yes, specify where_________________________________________________

Mucous Membranes: ☐ WNL ☐ Moist ☐ Dry ☐ Other________­­­_ ☐ Unknown

Eyes: ☐ WNL ☐ Pupils dilated ☐ Pupils constricted ☐ Nystagmus ☐ Other_________ ☐ Unknown

Cardiovascular: ☐ WNL ☐ Tachycardia ☐ Bradycardia ☐ Irregular heart rhythm ☐ Other_________ ☐ Unknown

Respiratory: ☐ WNL ☐ Bradypnea ☐ Tachypnea ☐ Dyspnea ☐ Shortness of breath ☐ Other_________ ☐ Unknown

Gastrointestinal: ☐ WNL ☐ Hypoactive bowel sounds ☐ Other_________ ☐ Unknown ☐ Hyperactive bowel sounds ☐ Tender

Genitourinary: ☐ WNL ☐ Urinary retention ☐ Other__________ ☐ Unknown

Neurologic: ☐ WNL ☐ Hyperreflexia ☐ Hyporeflexia ☐ Clonus ☐ Other _________ ☐ Unknown

Musculoskeletal: ☐ WNL ☐ Rigidity ☐ Weakness ☐ Other _______ ☐ Unknown If exam findings present, specify where (e.g., extremities, generalized)__________________

Initial Basic Laboratory Evaluation:

Blood Chemistry: Na________ K__________ Cl__________ HC03_______ BUN________ Creatinine____ Glucose_____

Date/Time ____________ ____________ ____________ ____________ ____________ ____________ ____________

Not Done _______________________________________________________________

Liver Panel: Total protein_____ Albumin_________ AST____________ ALT___________ Total bili________ Alk Phos________

Date/Time ____________________________ ______________ ______________ ____________________________

Not Done ______________________ ____________________________________________

Blood gas: pH_______­­___ Pa02_________ PaC02________ HC03________ ☐ Supplemental O2 If yes, Specify: _____L

Date/Time ___________ _________________________________

Not Done ____________________________________________

Other: ☐ CK (total serum) ______ ☐ Lactate/lactic acid: _____

Date/Time _____________ _____________

Not Done _____________ _____________

Toxicology / Drug Screen Evaluation:

Urine Drug Screen? ☐ Yes ☐ No If yes, mark all positives ☐ Barbiturates ☐ Benzodiazepines (BZD) ☐ Cocaine (benzylecgonine) ☐ Opiates ☐ Methadone ☐ Phencyclidine (PCP) ☐ Amphetamine ☐ Methamphetamine

☐ MDMA (Ecstasy) ☐ Phenylpropanolamine ☐ Cannabinoids (THC, Marijuana) ☐ Methaqualone ☐ Trazodone ☐ Tricyclic Antidepressants ☐ Other(s) ________________

Blood: ☐ Yes ☐ No If yes, mark all that apply ☐ Ethanol (specify blood level);__________ ☐ Salicylates (specify blood level);________ ☐ Acetaminophen (specify blood level);_____ ☐ Other (specify)______________________

Initial Electrocardiographic (ECG/EKG) or Telemetry Findings (e.g.): EKG done ☐ Yes ☐ No If yes, specify date/time (mm/dd/yy, hh:mm AM/PM): _________________________ Abnormal EKG? ☐ Yes ☐ No If abnormal, please specify: ☐ Arrhythmia (Specify______________________________) ☐ Long QT ☐ Short QT ☐ QRS interval abnormality ☐ Asystole ☐ Other, specify____________________

Imaging Findings (e.g. head CT, brain MRI, Chest X-ray, others): Imaging done ☐ Yes ☐ No If yes, check all that apply: Head CT ☐ Yes ☐ No Abnormal? ☐ Yes ☐ No Specific abnormal findings_____________________________________ Brain MRI ☐ Yes ☐ No Abnormal? ☐ Yes ☐ No Specific abnormal findings_____________________________________ Chest X-ray ☐ Yes ☐ No Abnormal? ☐ Yes ☐ No Specific abnormal findings_____________________________________ Other(s), ☐ Yes ☐ No Specify____________________________________________________ Specific abnormal findings_____________________________________

Interventions (mark all that apply): ☐ Yes ☐ No ☐ Intubation/Mechanical ventilation Specify reason (e.g. hypoventilation, airway protection) __________________ ☐ Extubation Date_____________ Time______________ ☐ Cardiopulmonary resuscitation ☐ Other(s) __________________________________ Medications ☐ Yes ☐ No ☐ Benzodiazepine (e.g. Ativan, Versed, Valium) Name:________________ Dose:___________ Time of Administration____________ Name:________________ Dose:___________ Time of Administration____________ ☐ Antipsychotics (e.g. Haldol, Geodon) Name:________________ Dose:___________ Time of Administration____________ Name:________________ Dose:___________ Time of Administration____________ ☐ Dissociative Anesthetics (e.g. Ketamine, Propofol) Name:________________ Dose:___________ Time of Administration____________ Name:________________ Dose:___________ Time of Administration____________ ☐ Antidotes (e.g. Glucose, Narcan, Physostigmine, Flumazenil) Name:________________ Dose:___________ Time of Administration____________ Name:________________ Dose:___________ Time of Administration____________ ☐ Other Name:________________ Dose:___________ Time of Administration____________ Name:________________ Dose:___________ Time of Administration____________ Name:________________ Dose:___________ Time of Administration____________ Name:________________ Dose:___________ Time of Administration____________

Past Medical History High blood pressure: ☐ Yes ☐ No ☐ Unknown Heart disease: ☐ Yes ☐ No ☐ Unknown Specify_______________________________ Kidney disease: ☐ Yes ☐ No ☐ Unknown Specify_______________________________ Liver disease: ☐ Yes ☐ No ☐ Unknown Specify_______________________________ Diabetes ☐ Yes ☐ No ☐ Unknown Specify_______________________________ Seizure disorder ☐ Yes ☐ No ☐ Unknown Specify_______________________________ Mental illness ☐ Yes ☐ No ☐ Unknown Specify_______________________________ Substance addiction ☐ Yes ☐ No ☐ Unknown Specify_______________________________ Other ☐ Yes ☐ No ☐ Unknown Specify_______________________________

Emergency Department Disposition: ☐ ED Observation, specify duration _____________(in HOURS) ☐ Deceased: ☐ Discharged _________(mm/dd/yy) _________(hh:mm) Date:_________(mm/dd/yy) ☐ Admitted to Hospital, specify admit date__________(mm/dd/yy) Time:_________(hh:mm) ☐ICU ☐General Medicine ☐Other____________________ ☐ Transferred to another hospital, specify date__________(mm/dd/yy) ☐ Unknown ☐ Left AMA _________(mm/dd/yy) _________(hh:mm)

Complications During ED Course ☐ None ☐ Seizures ☐ Psychosis ☐ Agitation

☐ Respiratory failure ☐ Multi-organ failure ☐ Hyperthermia ☐ Acute Kidney Injury/ Failure ☐ Rhabdomyolysis ☐ Coma ☐ Other, specify______________________________

Other Data/Notes:

SPECIMENS

Blood Specimen(s) available? (earliest available specimen(s) preferred) ☐ Yes ☐ No ☐ Unknown If yes, specify: Type of specimen _____________ Collection date ___________ Collection Time ____________ Type of specimen _____________ Collection date ___________ Collection Time ____________ Urine Specimen(s) available? (earliest available specimen (s) preferred) ☐ Yes ☐ No ☐ Unknown If yes, specify: Type of specimen _____________ Collection date ___________ Collection Time ____________ Type of specimen _____________ Collection date ___________ Collection Time ____________

Illicit substance/Product Specimen(s) available? ☐ Yes ☐ No ☐ Unknown If yes, specify: Type of specimen _____________ Collection date ___________ Collection Time ____________ Last known person or organization in possession of sample: __________________________________________

NB. If abstraction ends at this point, please go to last page to complete lab testing tier

C. Inpatient Record Review

Level of Care (during hospital stay): ☐ Intensive Care Unit Admit date__________ Discharge/ transfer date (if applicable)__________ (mm/dd/yy) ☐ Step-Down Unit Admit date__________ Discharge/ transfer date (if applicable)__________ (mm/dd/yy) ☐ General Medicine Admit date__________ Discharge/ transfer date (if applicable)__________ (mm/dd/yy) ☐ Telemetry Unit Admit date__________ Discharge/ transfer date (if applicable)__________ (mm/dd/yy) ☐ Psychiatry Unit Admit date__________ Discharge/ transfer date (if applicable)__________ (mm/dd/yy) ☐ ED Observation Admit date__________ Discharge/ transfer date (if applicable)__________ (mm/dd/yy) ☐ Other ____________ Admit date__________ Discharge/ transfer date (if applicable)__________ (mm/dd/yy) ☐ Unknown

Peak Laboratory Evaluation:

Blood Chemistry: Na_________ K__________ Cl__________ HC03_______ BUN________ Creatinine____ Glucose_____

Date/Time ____________ ____________ ____________ ____________ ____________ ____________ ____________

Not Done _____________ _____________ _____________ _____________ _____________ _____________ ____________

Liver Panel: Total protein_____ Albumin_________ AST____________ ALT___________ Total bili________ Alk Phos________

Date/Time ____________ ____________ ____________ ____________ ____________ ____________

Not Done _____________ _____________ _____________ _____________ _____________ _____________

Blood gas: pH_______­­___ Pa02_________ PaC02________ HC03________ ☐ Supplemental O2 If yes, Specify: _____L

Date/Time __________­­__ ____________ ____________ ____________

Not Done _____________ _____________ ­­_____________ _____________

Other: ☐ CK (total serum) ______ ☐ Lactate/lactic acid: _____

Date/Time ____________ ____________

Not Done ______________ ______________

Nadir Laboratory Evaluation:

Blood Chemistry: Na_________ K__________ Cl__________ HC03_______ BUN________ Creatinine____ Glucose_____

Date/Time ____________ ____________ ____________ ____________ ____________ ____________ ____________

Not Done _____________ _____________ _____________ _____________ _____________ _____________ _____________

Liver Panel: Total protein_____ Albumin_________ AST____________ ALT____________ Total bili________ Alk Phos________

Date/Time ____________ ____________ ____________ ____________ ____________ ____________

Not Done _____________ _____________ _____________ _____________ _____________ ____________

Blood gas: pH_______­­___ Pa02_________ PaC02________ HC03________ ☐ Supplemental O2 If yes, Specify: _____L

Date/Time __________­­__ ____________ ____________ ____________

Not Done _____________ _____________ ­­_____________ _____________

Other: ☐ CK (total serum) ______ ☐ Lactate/lactic acid: _____

Date/Time ____________ ____________

Not Done ______________ ______________

Electrocardiographic (ECG/EKG) or Telemetry Findings EKG done ☐ Yes ☐ No If yes, please specify date/time (mm/dd/yy)/(hh:mm A.M./P.M.)_____________________ Abnormal EKG? ☐ Yes ☐ No Date___________ Time_______________ If yes, please specify: ☐ Arrhythmia (Specify__________________) ☐ Long QT ☐ Short QT ☐ QRS interval abnormality ☐ Asystole ☐ Other, specify___________________________

Interventions (mark all that apply): ☐ Yes ☐ No ☐ Intubation/Mechanical ventilation Specify reason (e.g. hypoventilation, airway protection) _______________ ☐ Extubation Date_____________ Time______________ ☐ Cardiopulmonary resuscitation Date_____________ Time______________ ☐ Other(s) _______________________________________________________ Medications ☐ Yes ☐ No ☐ Benzodiazepine (e.g. Ativan, Versed, Valium) Name:_______________________ Number of Times Given____________ Name:___________ ____________ Number of Times Given____________ ☐ Antipsychotics (e.g. Haldol, Geodon) Name:________________________ Number of Times Given____________ Name:________________________ Number of Times Given____________ ☐ Dissociative Anesthetics (e.g. Ketamine, Propofol) Name:_______________________ Number of Times Given____________ Name:_______________________ Number of Times Given____________ ☐ Antidotes (e.g. Glucose, Narcan, Physostigmine, Flumazenil) Name:_______________________ Number of Times Given____________ Name:_______________________ Number of Times Given____________ ☐ Other Name:_______________________ Number of Times Given____________ Name:_______________________ Number of Times Given____________ Name:_______________________ Number of Times Given____________ Name:_______________________ Number of Times Given____________

Complications During Hospital Course ☐ None ☐ Seizures ☐ Psychosis ☐ Agitation ☐ Respiratory failure ☐ Mechanical Ventilation

☐ Hyperthermia ☐ Rhabdomyolysis ☐ Acute Kidney Injury/ Failure ☐ Multi-organ failure, etc.) ☐ Coma ☐ Other, specify___________________

Outcome: ☐ Discharged Date of Discharge _________(mm/dd/yy) ☐ Discharge diagnoses, specify_______________________ ☐ Discharged against medical advice, specify_______________________ ☐ Discharge diagnoses, specify_______________________ ☐ Still hospitalized ☐ Deceased Date and time of death ___________________ (mm/dd/yy)/(hh:mm A.M./P.M.) ☐ Unknown

Other Data/Notes:

D. ME or Coroner Record Review

Date and Time of Death (mm/dd/yy)/(hh:mm A.M./P.M.): ☐ Check if time of death is estimated

Significant Positive Gross Autopsy Findings:

Significant Positive Histopathology Autopsy Findings:

Significant Positive Laboratory Autopsy Findings (please include both positive and negative toxicologic laboratory findings):

Source of Blood Samples ☐ Core ☐ Peripheral ☐ Other (specify) ______________________ Time specimen obtained (if available) (mm/dd/yy, hh:mm AM/PM):__________________

Other Data/Notes (please include any past medical history or any pertinent case history listed): Case Definition Determination & Lab Testing Tier

Is the case: ☐ Probable If probable, select lab testing tier: ☐ 1 ☐ 2 ☐ 3 Please see reference below ☐ Suspect

*Case Definition:

Probable

Self-reported or other suspicion of synthetic cannabinoid (synthetic marijuana) use within 24 hours of onset of illness with or without other recreational substances

--OR—

Suspect

Suspected use of unknown recreational drug(s) within 24 hours of onset of illness, based on clinical presentation

*Only use this lab testing tier system to stratify patients who meet our PROBABLE CASE definition*

Tier 1:

• ICU admitted patients

-OR-

• Patients with symptoms consistent with synthetic cannabinoid exposure WITH environmental (drug) samples available for testing, regardless of admission status.

• Percentage of patients in this category that will have specimens tested = 100%

Tier 2:

• Patients admitted to Ed observation, step-down unit, general medical, or telemetry unit

• Percentage of patients in this category that will have specimens tested: 50%

Tier 3:

• Patients seen in the ER and discharged

• Percentage of charts in this category that will have specimens tested: 25% or number of additional specimens that will add up to 50

  • CO can only test 50 specimens. For example if we have 25 patients from tier 1, 10 patients from tier 2, then we will only be able to test 15 specimens from tier 2, regardless what percentage of Tier 3 patients this is.

  • Our priority of testing is primarily on patients in tier 1 and 2.

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)