1 00:00:00,000 --> 00:00:03,065 T.R. Eckler: The AI Soon we'll be like, Hey, patient uh, has 2 00:00:03,065 --> 00:00:04,715 vomited six times in bed eight. 3 00:00:04,835 --> 00:00:07,445 Have you considered cannabis hyperemesis in your diagnostic? 4 00:00:09,539 --> 00:00:12,299 Sam : Hi everyone, and welcome to another episode of EMPlify 5 00:00:12,299 --> 00:00:13,809 I'm your host, Sam Ashoo. 6 00:00:14,089 --> 00:00:18,039 Before we dive into this month's episode, I want to say thank you for joining us. 7 00:00:18,089 --> 00:00:21,629 I sincerely hope that you find it to be helpful and informative for your 8 00:00:21,629 --> 00:00:26,059 clinical practice, and I want to remind you that you can go to ebmedicine.net 9 00:00:26,129 --> 00:00:30,279 where you will find our three journals, Emergency Medicine Practice, Pediatric 10 00:00:30,289 --> 00:00:35,439 Emergency Medicine Practice, and Evidence Based Urgent Care, and a multitude of 11 00:00:35,459 --> 00:00:39,809 other resources, like the EKG course, the laceration course, interactive 12 00:00:39,809 --> 00:00:44,249 clinical pathways, just tons of information to support your practice 13 00:00:44,389 --> 00:00:45,999 and help you in your patient care. 14 00:00:46,269 --> 00:00:48,459 And now, let's jump into this month's episode. 15 00:00:49,119 --> 00:00:52,729 Welcome back ladies and gentlemen, to another episode of Emplify. 16 00:00:52,789 --> 00:00:56,799 I am one of your hosts, Sam Ashoo, in on the other side of the microphone. 17 00:00:57,159 --> 00:00:59,589 T.R. Eckler: Dr. TR Eckler, I come from Colorado. 18 00:00:59,649 --> 00:01:00,819 I've seen a lot of marijuana. 19 00:01:01,519 --> 00:01:04,369 Sam : As he says, apparently they have some of this stuff 20 00:01:04,419 --> 00:01:06,289 in Colorado, so he says, 21 00:01:06,664 --> 00:01:08,824 T.R. Eckler: I, I use that as my trading card with these patients 22 00:01:09,064 --> 00:01:10,954 because I would tell you, it immediately does score points. 23 00:01:10,954 --> 00:01:12,974 They're like, oh, oh, you, you're from Colorado. 24 00:01:13,024 --> 00:01:13,984 You know what you're talking about? 25 00:01:13,984 --> 00:01:14,224 I'm like, 26 00:01:14,224 --> 00:01:15,754 yeah, I've seen a lot of this. 27 00:01:16,399 --> 00:01:17,569 Sam : instant street cred. 28 00:01:18,932 --> 00:01:22,052 Okay, well that's a great introduction to what we're talking about today, 29 00:01:22,052 --> 00:01:26,402 which is the diagnosis and management of cannabis related emergencies. 30 00:01:26,402 --> 00:01:30,152 A very important topic and one we see very often in the emergency 31 00:01:30,152 --> 00:01:31,862 department, and if you work in an ED. 32 00:01:32,352 --> 00:01:33,942 You know exactly what I'm talking about. 33 00:01:34,372 --> 00:01:38,632 This is the December, 2025 issue of emergency medicine practice authored 34 00:01:38,632 --> 00:01:41,152 by Dr. Williams and Dr. Byram. 35 00:01:41,552 --> 00:01:47,012 And again, a very good job trying to review, I would say, the paucity 36 00:01:47,012 --> 00:01:49,232 of evidence about this condition. 37 00:01:49,482 --> 00:01:54,132 The authors did a good job of talking about not just cannabis hyperemesis 38 00:01:54,132 --> 00:02:00,432 syndrome, but all of the issues around cannabis and why it's current federal 39 00:02:00,432 --> 00:02:04,092 illegal status hinders clinical research. 40 00:02:04,092 --> 00:02:07,302 And so that's kind of one of the major contributors to why we have 41 00:02:07,302 --> 00:02:09,642 very little information about this. 42 00:02:09,832 --> 00:02:14,162 But they did summarize what we do know which I think was a pretty good review. 43 00:02:14,732 --> 00:02:20,162 The issue itself covers all of the things that are cannabis related, including 44 00:02:20,162 --> 00:02:25,252 even a little bit of a description of our legal status here in the United States. 45 00:02:25,252 --> 00:02:29,282 So 48 states including the District of Columbia and three 46 00:02:29,282 --> 00:02:33,302 other territories allow the use of cannabis for medicinal purposes. 47 00:02:33,512 --> 00:02:37,002 So, you know, most of the country in that scenario is accepting of 48 00:02:37,002 --> 00:02:39,222 marijuana use for medicinal purposes. 49 00:02:39,462 --> 00:02:43,662 There are eight states that allow only a specific type 50 00:02:43,662 --> 00:02:45,252 of the high potency products. 51 00:02:45,442 --> 00:02:50,462 And then there are 24 other states that will allow for non medicinal uses as well. 52 00:02:50,462 --> 00:02:55,652 So it's very much a hodgepodge of different laws across state borders. 53 00:02:55,892 --> 00:02:59,372 And if you're listening and you're not in our state of Florida, you 54 00:02:59,372 --> 00:03:03,062 probably have a completely different legal scenario to deal with. 55 00:03:03,422 --> 00:03:07,977 Interesting that because of the acceptance for medicinal and non 56 00:03:07,977 --> 00:03:12,212 medicinal uses, we've seen an increase in ED visits all over the country. 57 00:03:12,512 --> 00:03:17,132 The substance Abuse and Mental Health Services Administration has a report 58 00:03:17,162 --> 00:03:21,332 called Dawn or the Drug Abuse Warning Network, which estimates that there's 59 00:03:21,332 --> 00:03:25,592 about a million cannabis related emergency department visits that occurred last year, 60 00:03:25,802 --> 00:03:27,632 which is not an insignificant number. 61 00:03:27,852 --> 00:03:31,992 So a million visits with some kind of cannabis related problem. 62 00:03:32,192 --> 00:03:36,482 Most of them occurring in the younger population, 26 to 44. 63 00:03:36,762 --> 00:03:42,182 Especially in that kinda young teen, early twenties predominating and really 64 00:03:42,182 --> 00:03:45,002 covering a wide spectrum of presentations. 65 00:03:45,002 --> 00:03:48,302 Everything from nausea and vomiting to altered mental status 66 00:03:48,302 --> 00:03:51,852 and acute psychosis to you know, people with paranoid delusions. 67 00:03:51,852 --> 00:03:55,252 And so we see all kinds of things, and it primarily comes 68 00:03:55,252 --> 00:03:56,992 from the fact that it's not just. 69 00:03:57,207 --> 00:04:02,337 The plant derivative that we see, but also people reacting to the synthetics 70 00:04:02,547 --> 00:04:06,147 and the synthetics, depending on their chemical compound, may have 71 00:04:06,147 --> 00:04:08,577 nothing plant derived in them. 72 00:04:08,577 --> 00:04:11,517 And because of that, they're not necessarily illegal. 73 00:04:12,217 --> 00:04:17,377 They may not be banned substances and they may be available at your local vape 74 00:04:17,377 --> 00:04:19,757 shop under a bunch of different names. 75 00:04:20,057 --> 00:04:23,657 And that causes us problems in the ED because people come in saying, 76 00:04:23,657 --> 00:04:25,397 no, I'm not using any drugs. 77 00:04:25,587 --> 00:04:28,167 I have this perfectly legitimate thing, I buy over the counter 78 00:04:28,197 --> 00:04:30,027 and I smoke it every single day. 79 00:04:30,727 --> 00:04:34,027 That's when we discover, oh, okay, you're using some kind of synthetic 80 00:04:34,027 --> 00:04:38,677 that is trying to trigger these same receptors and causing you these problems. 81 00:04:39,017 --> 00:04:40,877 And that doesn't show up on a drug stream. 82 00:04:40,937 --> 00:04:46,777 So it's a very heterogeneous population of patients, but also of substances that 83 00:04:47,017 --> 00:04:50,097 people put under the blanket of cannabis. 84 00:04:50,587 --> 00:04:55,122 T.R. Eckler: This has been one of the defining kind of, you know, just 85 00:04:55,122 --> 00:05:00,042 increasing area of prevalence and treatment that's defined my career since 86 00:05:00,042 --> 00:05:01,932 I really started residency in 2012. 87 00:05:02,332 --> 00:05:08,017 We used to see a lot of synthetic cannabis in New York City because when 88 00:05:08,017 --> 00:05:13,282 I was there, marijuana was not legal and it was enough to make us want to 89 00:05:13,282 --> 00:05:17,302 advocate for better regulation and even legalization to get away from the 90 00:05:17,302 --> 00:05:22,332 synthetics because you were, as you said, you're talking about spraying some sort 91 00:05:22,332 --> 00:05:26,622 of chemical onto some sort of plant to make it look more natural and so you can 92 00:05:26,622 --> 00:05:29,802 burn it and smoke it, so people think it's something natural they're getting. 93 00:05:30,032 --> 00:05:34,007 But it's really just like some sort of herb or plant that's been sprayed and 94 00:05:34,007 --> 00:05:35,657 then, you know, then they go and smoke it. 95 00:05:35,657 --> 00:05:38,837 And we used to see seizures, we used to see respiratory failure. 96 00:05:38,987 --> 00:05:40,907 It was really something that was really challenging for us. 97 00:05:40,907 --> 00:05:43,547 'cause you just didn't know if and when they were gonna get better 98 00:05:43,547 --> 00:05:46,427 or if they needed to have, you know, more airway protection, 99 00:05:46,667 --> 00:05:48,317 more intensive things to be done. 100 00:05:48,617 --> 00:05:50,387 And it was a big drain on resources. 101 00:05:50,597 --> 00:05:54,927 And then to move from there to practicing Colorado after they had legalized. 102 00:05:55,277 --> 00:06:00,947 I saw so much use and I saw both the upsides and the downsides and 103 00:06:00,947 --> 00:06:04,737 just all the different ways that it makes people very, very sick. 104 00:06:04,957 --> 00:06:10,097 I have stories for days about this, but I think that the challenge is just 105 00:06:10,097 --> 00:06:11,477 the range of patients that it affects. 106 00:06:11,477 --> 00:06:15,197 You're talking about big ingestions in children all the way up to older people 107 00:06:15,197 --> 00:06:18,857 that think that they know what THC does to them, and then they get into some of 108 00:06:18,857 --> 00:06:22,096 the newer products that are out there that have way more THC than they ever 109 00:06:22,096 --> 00:06:25,726 experienced in their lives, and they come in with really severe symptoms. 110 00:06:25,726 --> 00:06:30,506 So it affects everybody and I think it's something that we need more research and 111 00:06:30,506 --> 00:06:34,346 as good a regulation as we could get to make this as safe as possible for people. 112 00:06:35,021 --> 00:06:35,741 Sam : Yeah, absolutely. 113 00:06:35,791 --> 00:06:40,141 And just to muddy the waters even more, there are some cannabis related 114 00:06:40,141 --> 00:06:42,781 products that are FDA approved. 115 00:06:42,781 --> 00:06:47,841 So you can find cannabis related products that are FDA approved for anorexia 116 00:06:47,841 --> 00:06:53,541 that's associated with HIV or AIDS or Chemotherapy induced nausea and vomiting 117 00:06:53,791 --> 00:06:56,551 or intractable seizures in children. 118 00:06:56,731 --> 00:07:00,246 Those are some of the examples where there are FDA products that 119 00:07:00,246 --> 00:07:04,456 have approval even for intractable spasticity from multiple sclerosis. 120 00:07:04,676 --> 00:07:05,906 But that's where it stops. 121 00:07:05,906 --> 00:07:08,636 And so that's where the evidence stops because those are the only 122 00:07:08,636 --> 00:07:10,496 things that have FDA approval. 123 00:07:10,956 --> 00:07:15,299 I thought the authors did a, very good job of describing what we know 124 00:07:15,299 --> 00:07:20,089 about the physiology of cannabis and how it affects the body. 125 00:07:20,489 --> 00:07:23,669 You know, they detailed in there a good description of cannabinoid one and 126 00:07:23,669 --> 00:07:27,609 cannabinoid two receptors and that the one receptors are found mostly in the, 127 00:07:27,746 --> 00:07:32,036 central nervous system and two receptors can be found really almost anywhere, but 128 00:07:32,036 --> 00:07:37,456 primarily in the immune system, which kinda is a pathophysiological mechanism 129 00:07:37,456 --> 00:07:39,766 for its anti-inflammatory effects. 130 00:07:40,156 --> 00:07:44,666 But the CB one or the cannabinoid one receptors in the nervous system 131 00:07:44,666 --> 00:07:47,606 are the ones where we're gonna find the majority of our clinical effects. 132 00:07:47,606 --> 00:07:52,196 And those are the things like everything from increased excitation all the 133 00:07:52,196 --> 00:07:57,386 way up to seizures, to modulation of dopamine and acetylcholine and glutamate 134 00:07:57,386 --> 00:07:59,396 and serotonin through GABA receptors. 135 00:07:59,616 --> 00:08:06,984 And so it has a, plethora of effects, which ironically is kind of moderated 136 00:08:07,044 --> 00:08:09,954 by the plant derived marijuana. 137 00:08:09,954 --> 00:08:13,901 The original thing that people used to grow and use in, multiple countries 138 00:08:13,961 --> 00:08:20,031 and cultures and now is in overdrive with synthetic cannabinoids, which 139 00:08:20,031 --> 00:08:25,422 are hundreds of times more potent and providing excess stimulation at those 140 00:08:25,422 --> 00:08:31,872 receptors far beyond what the organic or plant derived chemicals used to do. 141 00:08:32,112 --> 00:08:35,252 And that's where we see the other symptoms. 142 00:08:35,252 --> 00:08:38,822 So most people think of marijuana as something that's gonna kind of relax you, 143 00:08:38,882 --> 00:08:43,082 calm you, you know, sedate you, and yet we're seeing exactly the opposite effect 144 00:08:43,082 --> 00:08:48,302 from the synthetics or even the high potency plants because you're just getting 145 00:08:48,362 --> 00:08:50,882 way overstimulation of these receptors. 146 00:08:51,182 --> 00:08:56,413 And then with chronic users, we get a whole nother different pathophysiology 147 00:08:56,413 --> 00:09:00,583 where these receptors can get downregulated and then if people stop, 148 00:09:00,583 --> 00:09:02,203 they can get withdrawal symptoms. 149 00:09:02,203 --> 00:09:06,523 If people continue to use, they can get a whole host of other symptoms that are 150 00:09:06,523 --> 00:09:09,943 kind of thought of as things that you would normally use marijuana to treat. 151 00:09:09,943 --> 00:09:14,600 So persistent nausea and vomiting is something that I'm constantly discussing 152 00:09:14,600 --> 00:09:18,140 with people who use marijuana on the regular because they think, oh, well this 153 00:09:18,140 --> 00:09:20,600 is something my marijuana would cure. 154 00:09:20,690 --> 00:09:22,910 There's no way it's the cause for these symptoms. 155 00:09:22,910 --> 00:09:26,880 And then we have to go down this whole explanation of why that's 156 00:09:26,880 --> 00:09:30,390 not correct and what we know about cannabis hyperemesis syndrome. 157 00:09:30,390 --> 00:09:33,840 So yeah, I think the authors did a great job of just describing that 158 00:09:33,840 --> 00:09:38,010 pathophysiology and at the very least, describing the complexity 159 00:09:38,070 --> 00:09:39,920 of how all of this fits together. 160 00:09:40,595 --> 00:09:43,645 T.R. Eckler: And the biggest struggle is just there's so many different products 161 00:09:43,855 --> 00:09:48,505 that are aimed at like targeting this pathway and you just can't test for it. 162 00:09:48,505 --> 00:09:51,915 It's not like one drug, like alcohol or you know, nicotine where you 163 00:09:51,915 --> 00:09:53,022 at least know what the drug is. 164 00:09:53,245 --> 00:09:56,245 And as they make certain ones illegal, other ones pop up. 165 00:09:56,245 --> 00:09:59,955 So it's a very wild west time in this area and I think that's why it's really 166 00:09:59,955 --> 00:10:03,219 important to talk about it and advocate really strongly for more research 167 00:10:03,289 --> 00:10:03,679 . Sam : Yeah. 168 00:10:03,829 --> 00:10:04,519 Yeah, absolutely. 169 00:10:04,519 --> 00:10:08,059 And talk to your children about it, because many of these things are 170 00:10:08,059 --> 00:10:11,764 marketed at the younger population, so they just need to be aware that 171 00:10:11,764 --> 00:10:15,124 just 'cause it's available at your local vape shop does not make it safe. 172 00:10:15,824 --> 00:10:16,004 All right. 173 00:10:16,004 --> 00:10:19,034 Let's talk about a couple of helpful resources here before we 174 00:10:19,034 --> 00:10:20,924 jump into the clinical effects. 175 00:10:21,024 --> 00:10:25,434 There is a table on page five which discusses all of the different routes 176 00:10:25,464 --> 00:10:29,214 that these are now available in, which is something that's new in the past decade. 177 00:10:29,214 --> 00:10:32,244 So it used to be you had to smoke it and that was the only 178 00:10:32,244 --> 00:10:34,164 route to inhale it into your body. 179 00:10:34,164 --> 00:10:38,139 But now there are ways to ingest it in capsules and tablets 180 00:10:38,139 --> 00:10:39,609 and even ingestible oils. 181 00:10:39,819 --> 00:10:41,989 There's transmucosal ways. 182 00:10:41,989 --> 00:10:45,559 So, you know, sublingual oral tinctures and sprays as you mentioned. 183 00:10:45,809 --> 00:10:47,819 And some hard candies that you can suck on. 184 00:10:47,819 --> 00:10:50,849 There are even rectal suppositories for methods of delivery. 185 00:10:51,159 --> 00:10:55,389 And then there's topical transdermal, so creams, gels, patches, and oils. 186 00:10:55,389 --> 00:10:57,009 And really the sky is the limit. 187 00:10:57,009 --> 00:10:59,139 If there is some way for your body to absorb it. 188 00:10:59,229 --> 00:11:02,169 There is a product out there that's available in that formulation. 189 00:11:02,169 --> 00:11:06,559 So you have to ask that piece in your history and just say, Hey, you know, 190 00:11:06,559 --> 00:11:10,699 are you using any of these products in any one of these delivery mechanisms? 191 00:11:10,919 --> 00:11:13,244 T.R. Eckler: And also like exactly what is your delivery mechanism. 192 00:11:13,244 --> 00:11:17,584 We had a lot of people using wax and very like, concentrated oils. 193 00:11:17,764 --> 00:11:21,784 And they would basically use an acetylene torch to burn them and vaporize them and 194 00:11:21,784 --> 00:11:22,864 then they would inhale them that way. 195 00:11:22,864 --> 00:11:27,394 And we had a few patients in Colorado who got Pneumomediastinum from basically, 196 00:11:27,724 --> 00:11:31,794 you know, popping a hole in their airway from this superheated cannabis wax. 197 00:11:31,794 --> 00:11:35,664 So it's important to ask that 'cause it gives you a bigger sense of 198 00:11:35,664 --> 00:11:36,894 kind of what their risk level is. 199 00:11:36,894 --> 00:11:39,534 And also if they're gonna show you something about inflammation in 200 00:11:39,534 --> 00:11:42,444 your lungs, like some kind of a vape lung, you can get that from 201 00:11:42,444 --> 00:11:43,554 some of these products as well. 202 00:11:44,254 --> 00:11:44,974 Sam : Great points. 203 00:11:45,440 --> 00:11:50,240 And then when we talk about the drug effects, the author's broke this down 204 00:11:50,240 --> 00:11:52,460 into multiple categories based on systems. 205 00:11:52,460 --> 00:11:56,870 So the psychiatric effects being the biggest one, and again, ironically 206 00:11:56,905 --> 00:12:01,315 symptoms occur that we think of as symptoms you would treat with cannabis. 207 00:12:01,315 --> 00:12:05,915 So things like anxiety and panic attacks and paranoia and acute psychosis 208 00:12:05,915 --> 00:12:07,715 with hallucinations and delusions. 209 00:12:07,965 --> 00:12:11,535 These are symptoms of acute intoxication, especially with the 210 00:12:11,535 --> 00:12:13,905 synthetics that people can present with. 211 00:12:13,950 --> 00:12:15,840 And it can be very aggressive. 212 00:12:15,840 --> 00:12:19,500 It can be severely agitated all the way down to the depressive 213 00:12:19,500 --> 00:12:21,720 and comatose and unresponsive. 214 00:12:21,910 --> 00:12:26,290 That spectrum is very, very wide, but all of those psychiatric effects 215 00:12:26,500 --> 00:12:28,570 in acute intoxication can be seen. 216 00:12:28,960 --> 00:12:32,740 And then there are the cardiovascular effects, which I thought was 217 00:12:32,800 --> 00:12:36,610 exceptionally enlightening here, you know, obviously there's tachycardia. 218 00:12:36,615 --> 00:12:40,720 You can get some hemodynamic instability, hypertension or postural 219 00:12:40,720 --> 00:12:45,760 hypotension or, interestingly, a decrease in your anginal threshold. 220 00:12:45,760 --> 00:12:49,540 There was actually one article cited by the authors that showed a fivefold 221 00:12:49,540 --> 00:12:53,950 increase in the risk of MI in the first hour of cannabis use, which 222 00:12:54,070 --> 00:12:58,600 eventually waned as you kind of continued using it beyond the first hour. 223 00:12:58,870 --> 00:13:03,255 But if you have any kind of propensity to coronary artery disease or any 224 00:13:03,280 --> 00:13:07,555 risk factors, now all of a sudden you've quintupled that risk in the 225 00:13:07,555 --> 00:13:09,385 first hour by smoking marijuana. 226 00:13:09,635 --> 00:13:12,725 Which again, is not something that's popularly advertised, but 227 00:13:12,725 --> 00:13:13,985 something we need to be aware of. 228 00:13:14,685 --> 00:13:18,825 There was also a discussion about the synthetics affecting QT syndrome. 229 00:13:18,855 --> 00:13:24,835 So you can lengthen your QT on your EKG and give you a propensity to arrhythmias 230 00:13:24,835 --> 00:13:28,835 and ventricular dysrhythmias because you're smoking marijuana or using one 231 00:13:28,835 --> 00:13:33,425 of these synthetic drugs, which again, is not something we think about, but is 232 00:13:33,425 --> 00:13:36,785 important because if we're going to be treating them and we're using something 233 00:13:36,785 --> 00:13:41,025 else that will also prolong their qt we're just kind of adding these effects up. 234 00:13:41,565 --> 00:13:44,835 The pulmonary effects includes things like bronchospasm and 235 00:13:44,835 --> 00:13:48,525 exacerbating your underlying asthma or COPD or pulmonary disease. 236 00:13:48,860 --> 00:13:50,390 There are renal effects. 237 00:13:50,390 --> 00:13:54,200 You can get acute tubular necrosis or acute interstitial nephritis from 238 00:13:54,200 --> 00:13:58,370 the drugs, especially the synthetic versions, and you can get rhabdomyolysis. 239 00:13:58,370 --> 00:14:03,890 And so there are all kinds of effects on every single system. 240 00:14:04,095 --> 00:14:07,395 The metabolic effects include everything from hypothermia 241 00:14:07,395 --> 00:14:12,045 to hypoglycemia, hypokalemia, hyponatremia, and metabolic acidosis. 242 00:14:12,345 --> 00:14:17,065 You can get dry mouth and dental effects, and you can get even ocular effects. 243 00:14:17,095 --> 00:14:20,659 And so I say virtually every system in your body is affected by it. 244 00:14:20,659 --> 00:14:23,629 The receptors are everywhere, even though they're primarily in the central 245 00:14:23,629 --> 00:14:26,239 nervous system, no system goes untouched. 246 00:14:26,939 --> 00:14:30,089 And then there's a description of cannabinoid hyperemesis syndrome. 247 00:14:30,089 --> 00:14:34,319 So if you're not familiar with it, cannabinoid hyperemesis syndrome 248 00:14:34,349 --> 00:14:40,069 is something that occurs in chronic users and begins as nausea. 249 00:14:40,399 --> 00:14:44,359 Poor appetite, maybe some anorexia progresses to persistent severe 250 00:14:44,359 --> 00:14:48,409 nausea, vomiting, and can come with significant abdominal pain and retching 251 00:14:48,649 --> 00:14:52,069 that can become intractable and end them up in an emergency department. 252 00:14:52,369 --> 00:14:58,059 And is often really difficult to treat because people get resistant to the 253 00:14:58,059 --> 00:15:02,049 typical things that we use for nausea and vomiting, and they require higher 254 00:15:02,049 --> 00:15:06,909 and higher doses, and each time they have a flare, it's more severe and 255 00:15:07,159 --> 00:15:11,179 oftentimes, there's lots of discussions that occur trying to convince someone 256 00:15:11,179 --> 00:15:14,179 that it's actually the cannabis use that's causing this problem. 257 00:15:14,359 --> 00:15:19,099 And so they present with a history of multiple ED visits, multiple specialty 258 00:15:19,099 --> 00:15:21,889 visits with gastroenterologists, multiple procedures performed 259 00:15:21,889 --> 00:15:23,389 without an underlying etiology. 260 00:15:23,569 --> 00:15:27,584 It can be very complicated to treat but it does come with three phases. 261 00:15:27,689 --> 00:15:32,219 You get that prodrome where you have lots of nausea, and then you get the 262 00:15:32,219 --> 00:15:36,565 hyperemesis phase, which comes with a lot of nausea and vomiting and persistent 263 00:15:36,565 --> 00:15:38,005 vomiting with some abdominal pain. 264 00:15:38,215 --> 00:15:41,365 And then hopefully you get that recovery after you've been hydrated 265 00:15:41,365 --> 00:15:45,595 and treated if the nausea is stopped back and then into your normal state. 266 00:15:45,875 --> 00:15:48,665 And if you're a chronic user, then you're just gonna cycle through this 267 00:15:48,695 --> 00:15:50,225 again and again and again and again. 268 00:15:50,885 --> 00:15:54,885 And the typical nausea and vomiting, that persistent nausea 269 00:15:54,945 --> 00:15:59,055 and vomiting phase, phase two can last anywhere from 24 to 48 hours. 270 00:15:59,055 --> 00:16:01,815 So we're usually seeing people in the ED who have tried a bunch 271 00:16:01,815 --> 00:16:04,875 of things at home because they've had this happen a bunch of times. 272 00:16:05,145 --> 00:16:10,565 And interestingly, one of the pathognomonic things about the syndrome 273 00:16:10,565 --> 00:16:13,895 is that people will eventually figure out either through Google searches or 274 00:16:13,895 --> 00:16:17,525 experimentation on their own, that there are some things they can do at home to 275 00:16:17,525 --> 00:16:20,975 try and help with the nausea and vomiting and hot showers happens to be one of them. 276 00:16:20,975 --> 00:16:24,425 And so that is one of the historical questions we can ask is, Hey, have 277 00:16:24,425 --> 00:16:25,565 you tried treating this at home? 278 00:16:25,745 --> 00:16:27,065 What works for you at home? 279 00:16:27,065 --> 00:16:30,065 And if they talk about hot showers or if you probe them with that question 280 00:16:30,065 --> 00:16:33,905 and they say, yes, that can be indicative of this particular syndrome. 281 00:16:34,605 --> 00:16:37,605 T.R. Eckler: I think it's always good to ask them too, like, does you know 282 00:16:37,605 --> 00:16:39,285 any kind of THC use trigger this? 283 00:16:39,285 --> 00:16:40,995 Or was there an inciting event? 284 00:16:41,385 --> 00:16:45,807 I find that a lot of times people that aren't necessarily big THC users will use 285 00:16:45,807 --> 00:16:50,757 someone else's vape or inhaler type device and they'll get a very, very high dose of 286 00:16:50,757 --> 00:16:55,107 THC from like a, you know, prescription grade device or something like that. 287 00:16:55,407 --> 00:16:58,317 And all of a sudden they get a much higher dose than they've ever been exposed to. 288 00:16:58,317 --> 00:17:03,487 And that triggers them to go into acute CHS and then, if that, or if 289 00:17:03,487 --> 00:17:06,997 their use starts to cause them to have this nausea and the vomiting. 290 00:17:07,177 --> 00:17:10,567 I think that gives you a key that some of your kind of typical nausea 291 00:17:10,567 --> 00:17:12,592 medicines aren't gonna work and you need to try something different. 292 00:17:13,292 --> 00:17:13,532 Sam : Yeah. 293 00:17:14,232 --> 00:17:14,412 Yep. 294 00:17:15,112 --> 00:17:17,902 And then there is a withdrawal syndrome. 295 00:17:17,902 --> 00:17:21,972 It's been described especially in the chronic users that that this withdrawal 296 00:17:21,972 --> 00:17:26,982 can occur anywhere from 24 to 72 hours after last use, and can last anywhere 297 00:17:26,982 --> 00:17:31,572 from two to six days, and can come with really a lot of irritability, anxiety, 298 00:17:31,572 --> 00:17:36,467 depression, restlessness, poor sleep, or lack of sleep, tremors, muscle twitching. 299 00:17:36,912 --> 00:17:42,402 GI distress and headache, and anywhere from, at least in the limited data 300 00:17:42,402 --> 00:17:47,262 we have, up to 73% of individuals attempting to stop cannabis will 301 00:17:47,262 --> 00:17:50,772 experience at least some of these, especially the sleep difficulty. 302 00:17:50,982 --> 00:17:54,342 And so that may be the presenting symptom to the emergency department 303 00:17:54,512 --> 00:17:58,052 and just makes it again, even more important to ask those questions. 304 00:17:58,262 --> 00:18:03,002 If they're withdrawing from synthetic cannabinoids, there might be seizures, 305 00:18:03,032 --> 00:18:05,132 psychosis, and delirium as well. 306 00:18:05,132 --> 00:18:09,572 So just another plug that if you're using the synthetic cannabinoids, your 307 00:18:09,572 --> 00:18:13,142 symptoms are going to be far exaggerated, far worse, whether that's on the 308 00:18:13,142 --> 00:18:14,942 withdrawal side or the intoxication side. 309 00:18:15,642 --> 00:18:15,792 T.R. Eckler: Yeah. 310 00:18:15,792 --> 00:18:19,152 And if, someone's basically coming in with cannabis hyperemesis, you're gonna 311 00:18:19,152 --> 00:18:23,082 have to try to convince them they need to stop using for a month to try to 312 00:18:23,082 --> 00:18:25,452 allow their system to wash out and reset. 313 00:18:25,592 --> 00:18:29,562 And I think that counseling them on, you know, how they can manage their symptoms 314 00:18:29,562 --> 00:18:33,102 at home, counseling them on the withdrawal period and the fact that it's gonna be bad 315 00:18:33,102 --> 00:18:36,672 for maybe two or three days but then it'll start getting better, I think gives them 316 00:18:36,672 --> 00:18:39,762 an idea of like what they're gonna have to get through to start getting better. 317 00:18:39,912 --> 00:18:41,842 And it gives 'em a better timeline of where they're at. 318 00:18:42,542 --> 00:18:42,782 Sam : Yeah. 319 00:18:43,199 --> 00:18:47,519 And the differential diagnosis for it is very big because it's persistent 320 00:18:47,519 --> 00:18:49,049 nausea and vomiting and abdominal pain. 321 00:18:49,049 --> 00:18:52,039 And so you could think of, you know, life-threatening things as 322 00:18:52,062 --> 00:18:53,142 they have headache associated. 323 00:18:53,142 --> 00:18:55,842 They could have something in their brain, a central nervous system lesion. 324 00:18:56,032 --> 00:18:59,302 They're gonna have electrolyte abnormalities, low glucose, low 325 00:18:59,422 --> 00:19:03,497 sodium, low potassium meningitis and encephalitis can certainly cause 326 00:19:03,497 --> 00:19:05,147 headaches and altered mental status. 327 00:19:05,217 --> 00:19:09,057 Intoxication with a bunch of other substances may also be occurring. 328 00:19:09,087 --> 00:19:11,217 And so, you know, especially if they're buying it off the street, 329 00:19:11,217 --> 00:19:12,447 you don't know what's mixed with it. 330 00:19:12,447 --> 00:19:14,577 So polysubstance ingestion is a big one. 331 00:19:14,827 --> 00:19:16,460 Sympathomimetic intoxication. 332 00:19:16,460 --> 00:19:20,090 And then there are gonna be psychiatric things like acute psychosis. 333 00:19:20,090 --> 00:19:23,270 If they have a history of schizophrenia and they're a chronic user and now 334 00:19:23,270 --> 00:19:26,270 they're using the synthetics, it can either exacerbate those symptoms 335 00:19:26,270 --> 00:19:29,360 or it can be the underlying cause and things like panic attacks. 336 00:19:29,360 --> 00:19:32,610 And so there's a lot of things to keep in mind in your differential. 337 00:19:32,770 --> 00:19:35,750 And that doesn't even get into the differential of just intractable 338 00:19:35,750 --> 00:19:38,840 vomiting and abdominal pain, which includes everything from, you know, 339 00:19:38,840 --> 00:19:42,510 like cyclic vomiting to you know, bowel obstruction and appendicitis and 340 00:19:42,510 --> 00:19:44,430 surgical issues and gallbladder problems. 341 00:19:44,430 --> 00:19:50,915 And this is part of the reason why people are hard to convince that it's a cannabis 342 00:19:50,915 --> 00:19:54,035 related issue because there's so many other things and you know the chances that 343 00:19:54,035 --> 00:19:58,925 we are gonna find something, even though it may not be the cause, but something on 344 00:19:58,925 --> 00:20:01,415 your CT abdomen and labs are pretty high. 345 00:20:01,415 --> 00:20:03,785 You know your sodium's gonna be low, your potassium's gonna be 346 00:20:03,785 --> 00:20:05,315 low, you're gonna be dehydrated. 347 00:20:05,730 --> 00:20:07,260 You might have some gallstones. 348 00:20:07,290 --> 00:20:09,960 It may be completely unrelated, but you might have some gallstones. 349 00:20:09,960 --> 00:20:13,200 And so I have seen people who go down that entire path, get their 350 00:20:13,200 --> 00:20:16,380 gallbladder removed, end up being diagnosed with functional abdominal 351 00:20:16,380 --> 00:20:19,170 pain, nobody understands why, and end up on some other meds. 352 00:20:19,170 --> 00:20:22,110 And then finally, someone asks about the marijuana use and they go, oh 353 00:20:22,110 --> 00:20:23,310 no, there's no way that could be it. 354 00:20:23,310 --> 00:20:25,410 And I go, Hey, you have tried everything else. 355 00:20:25,500 --> 00:20:27,030 You've had organs removed. 356 00:20:27,180 --> 00:20:30,780 It might be time to give the marijuana a break for about six weeks 357 00:20:30,780 --> 00:20:32,200 and see if your symptoms go away. 358 00:20:32,900 --> 00:20:36,320 When it comes to the pre-hospital care, really it's just what we 359 00:20:36,320 --> 00:20:38,420 always rely on our paramedics for. 360 00:20:38,420 --> 00:20:41,750 So asking that history, looking for pill bottles, trying to help us figure out 361 00:20:41,750 --> 00:20:44,450 if there's been some other ingestion, especially if there's altered mental 362 00:20:44,450 --> 00:20:50,240 status when it comes to the ED history, I rely a lot on family members or 363 00:20:50,240 --> 00:20:51,860 anyone else who's with the patient. 364 00:20:52,080 --> 00:20:55,080 Because the patient sometimes isn't able to answer questions, especially 365 00:20:55,080 --> 00:20:58,110 if there's altered mentation, but sometimes they're not willing to either. 366 00:20:58,110 --> 00:21:01,140 You know, family members are way more willing to say, oh yeah, people have 367 00:21:01,140 --> 00:21:04,680 tried to tell this person to stop using this product, this spice product, 368 00:21:04,680 --> 00:21:06,630 or this over the counter synthetic. 369 00:21:06,880 --> 00:21:08,230 And the person won't listen. 370 00:21:08,500 --> 00:21:11,650 Or, yes, they've had this conversation multiple times before, 371 00:21:11,650 --> 00:21:13,830 but they stopped for a while and now they've gone back to it. 372 00:21:13,830 --> 00:21:16,620 You know, that kind of history is very, very, very important. 373 00:21:17,320 --> 00:21:21,100 When you're looking at the physical examination, it's gonna be, you know, 374 00:21:21,160 --> 00:21:25,037 vital signs, trying to narrow your differential, looking for abdominal 375 00:21:25,037 --> 00:21:29,247 tenderness, trying to understand what exactly is the underlying cause for 376 00:21:29,247 --> 00:21:30,957 their persistent nausea and vomiting. 377 00:21:31,237 --> 00:21:33,157 And then we get into diagnostics. 378 00:21:33,157 --> 00:21:39,220 And really this depends heavily on Where they are in their presentation spectrum. 379 00:21:39,280 --> 00:21:40,900 So is this their first time ever? 380 00:21:41,020 --> 00:21:42,640 They're gonna undergo a lot of testing. 381 00:21:42,850 --> 00:21:47,650 If it's not their first time and this is their 150th visit and they just had a 382 00:21:47,650 --> 00:21:52,630 visit yesterday and they've already had 8 million CT scans and a bunch of labs, then 383 00:21:52,660 --> 00:21:54,430 you do have to take that into account. 384 00:21:54,590 --> 00:21:58,580 And so when we talk about our diagnostic studies, I think the spectrum is 385 00:21:58,580 --> 00:22:01,730 large, but you do have to take that with a grain of salt that, yeah. 386 00:22:01,950 --> 00:22:04,590 They've probably already had most of this done at some point. 387 00:22:04,920 --> 00:22:08,700 The most important thing to keep in mind is that your drug test is mostly 388 00:22:08,700 --> 00:22:11,400 unreliable if it's positive, okay? 389 00:22:11,400 --> 00:22:14,880 But there are some false positives, especially things oddly enough 390 00:22:14,880 --> 00:22:19,170 like ibuprofen and pantoprazole, which can give you false positives 391 00:22:19,170 --> 00:22:20,670 on your drug screen for marijuana. 392 00:22:20,950 --> 00:22:22,270 Lamotrigine can do it. 393 00:22:22,540 --> 00:22:25,930 Sustiva can do it if they have a history of HIV that can also give you 394 00:22:25,930 --> 00:22:27,720 a false positive on the drug screen. 395 00:22:27,880 --> 00:22:31,150 But more importantly, they may not test positive at all. 396 00:22:31,150 --> 00:22:34,970 If they're on a synthetic, they're gonna have no registration of that 397 00:22:34,970 --> 00:22:36,410 drug on the drug screen at all. 398 00:22:36,410 --> 00:22:39,430 So you really can't rely on that test very much. 399 00:22:39,910 --> 00:22:42,760 When it comes to laboratory examination, you definitely wanna look 400 00:22:42,760 --> 00:22:46,720 for coingestants and that includes things like Tylenol and aspirin. 401 00:22:47,030 --> 00:22:51,110 And you wanna consider, especially if they're having chest pain or cardiac 402 00:22:51,110 --> 00:22:54,710 related abnormalities, that you might need a troponin, you might need to look for 403 00:22:54,710 --> 00:22:59,700 rhabdo, you might need to get an EKG and get a chest x-ray and go down that route. 404 00:22:59,730 --> 00:23:04,207 They can get related myocarditis, pericarditis, MI. And if they're 405 00:23:04,207 --> 00:23:07,177 altered, it can be hard to elicit that history and if they're tachycardic. 406 00:23:07,267 --> 00:23:09,982 These are all reasons to be liberal in your testing. 407 00:23:10,657 --> 00:23:12,667 T.R. Eckler: I would tell you, all these people get EKGs from me. 408 00:23:12,667 --> 00:23:16,297 'cause I wanna know where their QT starts and their QRS is because almost 409 00:23:16,297 --> 00:23:19,477 all the medicines we're gonna pick are gonna have some effect on that QTC. 410 00:23:19,777 --> 00:23:22,087 So I think that's one thing that all these people are getting. 411 00:23:22,387 --> 00:23:26,917 And then I think I'm more inclined after this article to chase the troponin 412 00:23:26,917 --> 00:23:30,787 in the CK because I think that we're seeing more, and especially in some of 413 00:23:30,787 --> 00:23:34,177 the synthetic stuff, some of the sicker looking people, that's more something 414 00:23:34,177 --> 00:23:36,127 that I'm gonna wanna make sure is okay. 415 00:23:36,457 --> 00:23:38,347 But I would tell you the hardest thing about these people is 416 00:23:38,347 --> 00:23:41,467 they all tend to have a pretty significant degree of leukocytosis. 417 00:23:41,707 --> 00:23:45,607 And it's hard just because you know you're looking at someone that's unwell. 418 00:23:45,997 --> 00:23:49,267 And they're vomiting a bunch and you're like they had a CT, but 419 00:23:49,267 --> 00:23:50,257 they've got this white count. 420 00:23:50,497 --> 00:23:53,767 And I would tell you that in practice, I've seen so many of these people with 421 00:23:53,827 --> 00:23:57,397 legitimate white counts that never really have much on imaging or things like that. 422 00:23:57,637 --> 00:24:01,037 So I think to your point, if they have not had imaging, then I'm not opposed to that. 423 00:24:01,037 --> 00:24:04,067 But if they've already had, you know, the ultrasound and the CT in the last 424 00:24:04,067 --> 00:24:08,052 month or two I am not regularly imaging these people when they come in, if 425 00:24:08,052 --> 00:24:10,542 they're young and healthy and don't have a history of bowel obstruction or 426 00:24:10,542 --> 00:24:14,412 anything, because most often treatment tends to resolve their symptoms. 427 00:24:14,412 --> 00:24:17,832 And then I can basically say, all right, like if treatment's not working, then 428 00:24:17,832 --> 00:24:19,032 I start to think more about imaging. 429 00:24:19,032 --> 00:24:21,862 But I think a lot of times that they're gonna have a white count, 430 00:24:21,862 --> 00:24:24,502 they're gonna look pretty unwell until you start to turn around. 431 00:24:25,137 --> 00:24:25,467 Sam : Yeah. 432 00:24:25,737 --> 00:24:25,947 Yeah. 433 00:24:25,947 --> 00:24:29,337 And this is a great opportunity for some of that shared decision making 434 00:24:29,337 --> 00:24:33,237 where you ask them, Hey, you know, is this similar to your prior visit? 435 00:24:33,237 --> 00:24:33,807 Yes, it is. 436 00:24:33,837 --> 00:24:34,017 Okay. 437 00:24:34,017 --> 00:24:35,127 What worked last time? 438 00:24:35,307 --> 00:24:37,497 Do you have any idea what's triggering this? 439 00:24:37,497 --> 00:24:41,217 And if it's the same trigger again and the same medicine works, you 440 00:24:41,217 --> 00:24:45,297 know, you've had 50 abdominal CT scans, which haven't shown anything. 441 00:24:45,297 --> 00:24:46,857 I'm trying to save you some radiation. 442 00:24:46,977 --> 00:24:49,257 What do you think about not getting the scan today? 443 00:24:49,257 --> 00:24:51,357 And oftentimes they'll be like, oh, I don't even want the scan. 444 00:24:51,357 --> 00:24:54,297 You know, I just feel like I'm always getting it 'cause I'm coming to the ED, 445 00:24:54,327 --> 00:24:55,527 but I don't think they think I need that. 446 00:24:55,707 --> 00:24:58,587 I just want x, Y or Z, you know, at that point. 447 00:24:58,587 --> 00:25:00,477 So a good conversation to have. 448 00:25:00,837 --> 00:25:06,487 There are some recommended first line treatments that the authors mentioned. 449 00:25:06,677 --> 00:25:09,677 And again, we have a paucity of evidence, so what are we treating? 450 00:25:09,677 --> 00:25:11,417 We're treating clinical symptoms. 451 00:25:11,417 --> 00:25:16,007 So if they're agitated, tachycardic, having increased anxiety, you can 452 00:25:16,007 --> 00:25:19,967 use benzodiazepines to manage those kind of neuropsychiatric effects. 453 00:25:20,127 --> 00:25:23,967 There is the side effect of helping with some nausea with the benzodiazepines. 454 00:25:23,967 --> 00:25:27,477 So yes, there is a role for use of benzodiazepines and then 455 00:25:27,477 --> 00:25:28,977 you're gonna use antiemetics. 456 00:25:29,007 --> 00:25:32,517 You can start with things that are first line for all of us, like 457 00:25:32,517 --> 00:25:34,737 ondansetron is a purely antiemetic. 458 00:25:34,737 --> 00:25:37,407 You can use something that's a pro motility agent as well, 459 00:25:37,407 --> 00:25:40,657 like metoclopramide and mix and match some of those things. 460 00:25:40,997 --> 00:25:44,837 You are gonna want to get a baseline EKG, especially if you end up having 461 00:25:44,837 --> 00:25:46,787 to progress to second line agents. 462 00:25:46,967 --> 00:25:51,287 And these are agents that are gonna affect multiple receptors like the 463 00:25:51,287 --> 00:25:54,537 butyrophenones, like Haldol or droperidol. 464 00:25:54,667 --> 00:25:58,117 They may have QT effects, so it's helpful to get the ECG. 465 00:25:58,367 --> 00:26:02,357 But more importantly, they do have some sedation effects as well for some people. 466 00:26:02,557 --> 00:26:06,307 And in some cases experimenting with these, the patients will get 467 00:26:06,307 --> 00:26:07,567 to know, okay, this works for me. 468 00:26:07,567 --> 00:26:08,557 This doesn't work for me. 469 00:26:09,257 --> 00:26:12,977 And if it doesn't work for them, it's important to ask why, because it may 470 00:26:12,977 --> 00:26:14,807 just be a side effect of the medication. 471 00:26:15,227 --> 00:26:17,297 So, you know, dystonia is one of those. 472 00:26:17,297 --> 00:26:19,727 I think you mentioned that you've seen lots of patients who kind of 473 00:26:19,727 --> 00:26:22,037 will list one of these medicines as an allergy, when actually they 474 00:26:22,037 --> 00:26:23,207 just had a dystonic reaction. 475 00:26:23,522 --> 00:26:26,649 T.R. Eckler: And I think that in these kind of patients, to what you said, 476 00:26:26,649 --> 00:26:29,769 what has worked for them in the past and what hasn't worked is important. 477 00:26:29,979 --> 00:26:34,089 Because if you're gonna spend, you know, medicine that could prolong their QTC 478 00:26:34,269 --> 00:26:38,309 and you're choosing between Zofran, Phenergan, Haldol, or triperidol I think 479 00:26:38,309 --> 00:26:41,759 that it's really important for if they tell you, look, Zofran and phenergan don't 480 00:26:41,759 --> 00:26:43,049 work for me, then don't give it to 'em. 481 00:26:43,379 --> 00:26:47,969 Like if it's not working for them, for this start into a Haldol or droperidol. 482 00:26:48,359 --> 00:26:52,229 In my practice, I'm using more and more Zyprexa because I find that it 483 00:26:52,229 --> 00:26:56,019 seems safer overall as a medication when compared to the other two. 484 00:26:56,229 --> 00:26:58,539 There's less dystonic reactions and it lasts longer. 485 00:26:58,854 --> 00:27:00,594 So I find that patients get more relief. 486 00:27:00,864 --> 00:27:04,104 It also offers a dissolvable tablet that they can go home with. 487 00:27:04,404 --> 00:27:07,494 I'm not advocating for them to get large quantities of it, but I think 488 00:27:07,494 --> 00:27:11,664 that you then give them a pathway of getting through that 24, 48, 72 hours 489 00:27:11,664 --> 00:27:16,037 of really the bad part of the cannabis hyperemesis severe vomiting phase. 490 00:27:16,487 --> 00:27:18,257 I think that's really important when you think about trying to 491 00:27:18,257 --> 00:27:19,607 prevent bouncebacks to the ER. 492 00:27:19,907 --> 00:27:25,652 But I think that these medicines, if you can really clearly have a sense 493 00:27:25,652 --> 00:27:27,122 that this is cannabis hyperemesis. 494 00:27:27,272 --> 00:27:31,782 And you go to something like a Haldol, a droperidol or a Zyprexa, their nausea 495 00:27:31,802 --> 00:27:35,687 and vomiting gets better, their pain gets better, and they have like an obvious 496 00:27:35,687 --> 00:27:39,077 sense of relief when you walk in the room where they're significantly better. 497 00:27:39,377 --> 00:27:43,337 And I like starting at smaller doses and gradually coming up 'cause you hit the 498 00:27:43,337 --> 00:27:46,937 sweet spot for a lot of patients and you say, Hey, do you feel good enough now? 499 00:27:46,937 --> 00:27:48,137 Or do you think you want a little bit more? 500 00:27:48,137 --> 00:27:51,092 And I find that they are great judge of when they think they need a little 501 00:27:51,092 --> 00:27:53,820 more and they can kind of balance the sedating side effects of the 502 00:27:53,820 --> 00:27:58,120 medicine versus just their horrible, uncontrolled vomiting and nausea sense. 503 00:27:58,820 --> 00:27:59,030 Sam : Yeah. 504 00:27:59,030 --> 00:28:02,360 And if you're gonna use one of these butyrophenones the authors also did 505 00:28:02,360 --> 00:28:05,900 a good job of, you know, signaling that it can take about an hour from 506 00:28:05,900 --> 00:28:09,320 the time you give a dose to the time that they're gonna have some relief. 507 00:28:09,320 --> 00:28:13,760 So It's not as quick as Ondansetron or even metoclopramide when you're 508 00:28:13,760 --> 00:28:15,020 giving it for nausea and vomiting. 509 00:28:15,200 --> 00:28:19,145 And if they're retching, it's just like, you know, you kind of have to temper 510 00:28:19,145 --> 00:28:21,275 the fact that you hear it in that room. 511 00:28:21,425 --> 00:28:23,735 And you might get the nurses that going, okay, they're still retching, 512 00:28:23,735 --> 00:28:25,895 they're still retching, and go, okay, we just gotta give it a little time. 513 00:28:26,045 --> 00:28:30,165 It hasn't been an hour since the last dose, or it hasn't been enough 514 00:28:30,165 --> 00:28:31,875 time for this to really take effect. 515 00:28:32,225 --> 00:28:34,672 and that some of these medicines are sedating, so if you're giving them 516 00:28:34,672 --> 00:28:38,602 benzos, if you're giving them these butyrophenones, if they've already had 517 00:28:38,602 --> 00:28:41,932 a dose or two of an anti-emetic as well, you just gotta be careful that you're 518 00:28:41,932 --> 00:28:44,242 stacking sedating medications as well. 519 00:28:44,887 --> 00:28:47,644 T.R. Eckler: And that's why I'm trying to keep it simple and going straight 520 00:28:47,644 --> 00:28:52,364 to, you know, the medicines like Haldol and droperidol and Zyprexa because I 521 00:28:52,364 --> 00:28:56,414 would like to be using a medicine that I think is gonna be most effective if I'm 522 00:28:56,414 --> 00:28:59,504 gonna have those sedating side effects and not basically be limited by the 523 00:28:59,504 --> 00:29:02,349 other medicines sedation as to giving them more of what I think they need. 524 00:29:03,049 --> 00:29:03,319 Sam : Yeah. 525 00:29:03,769 --> 00:29:04,009 Yeah. 526 00:29:04,219 --> 00:29:06,769 And totally okay to have that discussion with the patient and say, 527 00:29:06,769 --> 00:29:09,575 Hey, these have dystonic side effects. 528 00:29:09,575 --> 00:29:12,785 So if you get to the point where you're having some spasms, muscle 529 00:29:12,785 --> 00:29:16,235 twitching, you feel a little bit more rigid at home, just take some Benadryl. 530 00:29:16,265 --> 00:29:19,625 Here's the dosing, here's how often you can take it and just anticipate 531 00:29:19,745 --> 00:29:21,545 this is not an allergic reaction. 532 00:29:21,695 --> 00:29:24,455 This is a normal side effect of the medicine, and all I'm trying 533 00:29:24,455 --> 00:29:26,975 to do is keep you from going home and coming right back again. 534 00:29:26,975 --> 00:29:29,045 'cause the medicine's worn off or something of that sort. 535 00:29:29,045 --> 00:29:31,815 So, there is some evidence for capsaicin. 536 00:29:31,815 --> 00:29:36,990 So capsaicin is a topical agent that can be given over the abdomen. 537 00:29:37,020 --> 00:29:41,700 And there is a pathophysiological mechanism described by the authors 538 00:29:41,700 --> 00:29:45,460 where it triggers these receptors that are generally kinda capped 539 00:29:45,460 --> 00:29:46,990 out already from marijuana. 540 00:29:46,990 --> 00:29:50,350 And now you're trying to just completely overwhelm these receptors 541 00:29:50,350 --> 00:29:52,180 and reduce the nausea and vomiting. 542 00:29:52,442 --> 00:29:54,572 And strangely enough, capsaicin does it. 543 00:29:54,785 --> 00:29:59,855 It comes in topical gels and creams and even patches that can be applied usually 544 00:29:59,855 --> 00:30:05,525 over the abdominal wall, anywhere from 0.025%, all the way up to 8% for patches. 545 00:30:05,795 --> 00:30:10,362 And some people will experience an improvement in their symptoms. 546 00:30:10,512 --> 00:30:13,212 Some people have already tried this at home before they've come in. 547 00:30:13,417 --> 00:30:16,627 some people, we experiment with it in the ED because we've kind of run out 548 00:30:16,627 --> 00:30:19,267 of our options and the only option left is to admit 'em to the hospital. 549 00:30:19,267 --> 00:30:20,647 And I go, okay, well, why not? 550 00:30:20,777 --> 00:30:22,067 What's the downside to trying this? 551 00:30:22,067 --> 00:30:24,287 So it's okay to experiment with some. 552 00:30:24,317 --> 00:30:28,697 Some will have relief as soon as 30 to 45 minutes from the application. 553 00:30:28,930 --> 00:30:31,660 If it hasn't worked at that point, it's probably not going to work. 554 00:30:32,360 --> 00:30:35,480 T.R. Eckler: We did it in rural Colorado a bunch because you were kind 555 00:30:35,480 --> 00:30:38,720 of debating between like admitting the patient and transferring the 556 00:30:38,720 --> 00:30:40,880 patient or you know, what you could do. 557 00:30:41,120 --> 00:30:45,070 And I would say that mixing this and, other medicines, I saw some 558 00:30:45,070 --> 00:30:47,680 efficacy to it, but it's also pretty uncomfortable for the patients. 559 00:30:47,680 --> 00:30:52,490 So I don't think it, really met my hope of trying to do no harm as 560 00:30:52,490 --> 00:30:53,630 I was doing good to the patients. 561 00:30:53,660 --> 00:30:56,840 'cause they're kind of like sitting there wincing, going, I feel a little better. 562 00:30:56,840 --> 00:30:58,540 But like, they don't look more comfortable. 563 00:30:58,540 --> 00:30:59,080 They just look like 564 00:30:59,125 --> 00:31:00,025 Sam : I'm distracted. 565 00:31:00,725 --> 00:31:01,655 T.R. Eckler: I am distracted. 566 00:31:02,355 --> 00:31:04,610 Sam : My abdomen's burning like crazy right now. 567 00:31:05,310 --> 00:31:06,180 Yeah, totally. 568 00:31:06,180 --> 00:31:12,107 And another thing to keep in mind is, I have seen physicians kind of punitively go 569 00:31:12,107 --> 00:31:17,567 slow with the treatment or undertreat the persistent nausea and vomiting, thinking 570 00:31:17,567 --> 00:31:21,197 there's some kind of malingering component to it because the person's also asking for 571 00:31:21,197 --> 00:31:22,937 pain medicine or something of that sort. 572 00:31:23,157 --> 00:31:26,307 And you just have to be careful because they can get complications 573 00:31:26,307 --> 00:31:28,872 from persistent nausea and vomiting, you know, Boerhaave syndrome. 574 00:31:28,872 --> 00:31:30,627 They can get injuries to their esophagus. 575 00:31:30,867 --> 00:31:33,237 They can aspirate, they can get pneumonitis, they can have 576 00:31:33,417 --> 00:31:36,357 all these other problems that come from persistent symptoms. 577 00:31:36,387 --> 00:31:41,062 And the safer side is to treat them for what they're actually presenting 578 00:31:41,062 --> 00:31:43,582 with and try and get it under control as quickly as possible. 579 00:31:43,942 --> 00:31:47,302 T.R. Eckler: I feel like you, you captured it perfectly earlier when you just hear 580 00:31:47,302 --> 00:31:50,962 that person, like in the ER that vomits and vomits again and vomits again. 581 00:31:50,962 --> 00:31:54,027 I feel like if you vomit, like three or four times in like 582 00:31:54,047 --> 00:31:55,397 five minutes and I can hear it. 583 00:31:55,547 --> 00:31:58,877 I'm walking over to your room to be like, hi, have you ever thought about 584 00:31:58,967 --> 00:32:00,497 this could be cannabis hyperemesis. 585 00:32:00,677 --> 00:32:01,167 Sam : Exactly. 586 00:32:01,202 --> 00:32:03,557 T.R. Eckler: feel like I have to slow roll the questions a little bit, and 587 00:32:03,557 --> 00:32:06,437 honestly there's some aspect of my practice it's like this where I'll ask 588 00:32:06,437 --> 00:32:09,257 'em what they've taken and they'll already have tried Zofran or something at home 589 00:32:09,467 --> 00:32:13,157 and I'll give them an anti-psychotic and they're like, wow, I feel so much better. 590 00:32:13,277 --> 00:32:15,827 And I'm like, Hmm, this is probably cannabis hyperemesis then. 591 00:32:15,827 --> 00:32:16,577 And then they kind of go. 592 00:32:16,857 --> 00:32:20,351 Oh, and it's, a little bit the chicken before the egg, but I think 593 00:32:20,351 --> 00:32:24,584 that, you know, it, gives them a sense of, ah, yeah, that makes sense. 594 00:32:24,704 --> 00:32:26,889 If this is what makes me better and that's what you think it is. 595 00:32:26,889 --> 00:32:29,189 Like, you know, there's no accusatory piece of it. 596 00:32:29,189 --> 00:32:31,929 It's just, Hey, this is what this works really good on. 597 00:32:32,489 --> 00:32:36,649 Sam : Yeah I put this in the sense and sounds of the ER category right there. 598 00:32:36,649 --> 00:32:41,579 There's a smell to c diff, there's a smell to pseudomonas, there's a smell to melana. 599 00:32:41,599 --> 00:32:44,599 There is a sound to cannabis hyperemesis syndrome. 600 00:32:44,599 --> 00:32:47,269 You just hear that retching and you go, yeah, we don't usually 601 00:32:47,269 --> 00:32:50,299 get this kind of retching, even in bowel obstruction like this. 602 00:32:50,299 --> 00:32:54,239 This is very significant and very classic for this disorder. 603 00:32:54,564 --> 00:32:55,254 Which is interesting. 604 00:32:55,284 --> 00:32:57,904 I don't, it'll be one thing to study really like, you know, the 605 00:32:57,904 --> 00:33:02,374 acoustic diagnostic sensitivity for cannabis hyperemesis syndrome. 606 00:33:02,379 --> 00:33:02,689 T.R. Eckler: Don't worry. 607 00:33:02,734 --> 00:33:07,209 The AI Soon we'll be like, Hey, patient uh, has vomited six times in bed. 608 00:33:07,209 --> 00:33:07,449 Eight. 609 00:33:07,569 --> 00:33:10,179 Have you considered cannabis hyperemesis in your diagnostic? 610 00:33:10,824 --> 00:33:11,154 Sam : That's right. 611 00:33:11,854 --> 00:33:14,764 There was a good discussion there of some special populations, and of 612 00:33:14,764 --> 00:33:18,514 course, pediatrics is one of them because, you know, again, they're 613 00:33:18,514 --> 00:33:20,254 getting marketed to children. 614 00:33:20,414 --> 00:33:26,327 And the authors cited a survey which found that about 14% were children 615 00:33:26,327 --> 00:33:30,377 between 12 and 17 years of age for people who were using marijuana. 616 00:33:30,567 --> 00:33:34,647 And in that same age group, 11% reported cannabis use in the last year, 617 00:33:34,767 --> 00:33:39,897 6% reported cannabis use in the last month in that age range, 12 to 17. 618 00:33:40,117 --> 00:33:43,054 And it's not an insignificant number of ED visits there. 619 00:33:43,424 --> 00:33:47,504 Making about 15% of the population of this category that are coming to the ER are 620 00:33:47,504 --> 00:33:50,079 gonna be children, and you have to ask. 621 00:33:50,779 --> 00:33:55,409 And then you have to be careful about the testing and also what 622 00:33:55,409 --> 00:33:56,819 you do with that information. 623 00:33:56,819 --> 00:34:01,499 You know, a child who tests positive for marijuana and is getting exposed 624 00:34:01,499 --> 00:34:05,699 at home or got into something, this is a reportable incident and they can 625 00:34:05,699 --> 00:34:07,439 end up getting taken out of that home. 626 00:34:07,659 --> 00:34:09,879 And I'm not saying you shouldn't test because of that, but just 627 00:34:09,879 --> 00:34:13,239 understand that there are multiple layers to this kind of visit. 628 00:34:13,239 --> 00:34:17,199 So treat the patient, get your testing done, but then understand you also 629 00:34:17,199 --> 00:34:20,799 have reporting responsibilities beyond that, if we're talking about a child. 630 00:34:21,367 --> 00:34:27,937 T.R. Eckler: Just the prevalence of gummy candy type THC edibles are so 631 00:34:27,937 --> 00:34:31,897 high that on a regular basis we're either seeing children in the ER or 632 00:34:31,897 --> 00:34:34,837 having them honestly transferred in to be admitted to our PICU 'cause 633 00:34:34,837 --> 00:34:36,547 they're essentially like unresponsive. 634 00:34:36,997 --> 00:34:40,327 And I find that this is a good time where you do a full workup on these kids. 635 00:34:40,472 --> 00:34:43,677 But I think a drug screen is helpful because it's nice if you get a 636 00:34:43,677 --> 00:34:47,427 positive drug screen that's clearly THC to stop, you know, a lumbar 637 00:34:47,427 --> 00:34:49,947 puncture or some of the other things that start to get talked about. 638 00:34:50,277 --> 00:34:53,442 So I, think that getting a drug screen is a good thing to get. 639 00:34:53,622 --> 00:34:57,192 I don't think you should hang your hat on it diagnostically here, given the age 640 00:34:57,192 --> 00:34:58,542 of synthetics and all the other things. 641 00:34:58,542 --> 00:35:02,502 But I still think it's worth having because especially in these young kids, 642 00:35:02,652 --> 00:35:05,442 when everyone will swear up and down, there's no way it could have happened. 643 00:35:05,682 --> 00:35:09,537 You know, it is just something where it all of a sudden, like an hour or 644 00:35:09,537 --> 00:35:13,167 two later, they come up with, oh yeah, that cousin came over, or this or that. 645 00:35:13,257 --> 00:35:16,317 They always find a scapegoat in the family to blame it on, and I think that's 646 00:35:16,317 --> 00:35:19,887 the thing where you've just gotta, you know, always keep an open mind to that. 647 00:35:20,137 --> 00:35:23,107 It's just one of these things that in pediatric populations, 648 00:35:23,107 --> 00:35:24,487 there's so much access to it. 649 00:35:24,727 --> 00:35:28,297 I try to make it as blame-free and kind of, you know, we're not, we're just 650 00:35:28,297 --> 00:35:29,947 here to take care of you and your child. 651 00:35:30,157 --> 00:35:32,677 We're not here to like immediately call CPS or anything else. 652 00:35:32,887 --> 00:35:36,307 Like Colorado CPS was generally encouraging us not to call 'em about 653 00:35:36,337 --> 00:35:40,387 pediatric ingestions because the bandwidth that they had was reasonable for a lot 654 00:35:40,387 --> 00:35:43,111 of things, but it wasn't gonna cover every time a kid got into an edible 655 00:35:44,056 --> 00:35:44,806 . Sam : Yeah, yeah. 656 00:35:44,806 --> 00:35:47,776 Well, and I can understand in Colorado where it's legal, but at least you 657 00:35:47,776 --> 00:35:50,356 know, in, other states, you just gotta be careful, right, know what your 658 00:35:50,356 --> 00:35:53,206 mandatory reporting guidelines are and make sure you stick with them. 659 00:35:53,576 --> 00:35:58,256 And interestingly, the children are more prone to coma and are more 660 00:35:58,256 --> 00:36:01,346 prone to respiratory failure than the adults, which is kind of strange. 661 00:36:01,346 --> 00:36:06,306 You know, up to 20% of children under 10 can get comatose from an ingestion, and 662 00:36:06,306 --> 00:36:09,666 up to 6% of them can require mechanical ventilation, which is not something we 663 00:36:09,666 --> 00:36:11,706 usually think about with cannabinoids. 664 00:36:11,706 --> 00:36:15,586 So, it's not typically a respiratory depression kind of scenario. 665 00:36:15,746 --> 00:36:19,506 And so you just gotta be super, super careful in that particular case that 666 00:36:19,506 --> 00:36:22,356 you're doing your best for the child and looking for all those other causes 667 00:36:22,356 --> 00:36:24,286 as well and not anchoring on something. 668 00:36:24,736 --> 00:36:29,126 And then there are the second set of special populations of the authors brought 669 00:36:29,126 --> 00:36:34,586 up, and that's our pregnant population, which again, very, very challenging. 670 00:36:34,706 --> 00:36:37,856 If you've got somebody who's a chronic marijuana user and you're trying 671 00:36:37,856 --> 00:36:40,706 to figure out are they throwing up because they're pregnant or are they 672 00:36:40,706 --> 00:36:44,481 throwing up because they have chronic marijuana use, exceptionally difficult. 673 00:36:44,961 --> 00:36:48,351 T.R. Eckler: Or just because you know now when you have morning 674 00:36:48,351 --> 00:36:52,101 sickness, I think it is becoming more and more socially acceptable. 675 00:36:52,281 --> 00:36:53,181 You have morning sickness. 676 00:36:53,211 --> 00:36:55,241 Oh, you should take some kind of marijuana for that. 677 00:36:55,421 --> 00:36:57,891 It will help with the nausea and the vomiting, and it's a 678 00:36:58,151 --> 00:37:00,251 challenging thing to work through. 679 00:37:00,431 --> 00:37:01,841 Is this morning sickness? 680 00:37:01,841 --> 00:37:05,441 Is it, you know, hyperemesis gravidarum, or is it CHS? 681 00:37:05,961 --> 00:37:10,601 I think that's another delicate area where you've gotta come in with no judgment. 682 00:37:10,601 --> 00:37:13,651 You've gotta come in with asking about are there vitamins triggering this? 683 00:37:13,861 --> 00:37:15,181 Is it foods that trigger this? 684 00:37:15,181 --> 00:37:18,571 Like what is triggering it and are hot showers making it better? 685 00:37:18,871 --> 00:37:22,021 And then you can kind of gradually try different things to see. 686 00:37:22,231 --> 00:37:25,451 Now this isn't a patient population you wanna give Haldol and droperidol. 687 00:37:25,471 --> 00:37:28,591 But if you look at in basically the OB literature. 688 00:37:28,591 --> 00:37:33,051 If you go down through the hyperemesis gravidarum medication list, Thorazine 689 00:37:33,051 --> 00:37:34,611 is really the bottom of that list. 690 00:37:34,731 --> 00:37:37,551 And Thorazine is not a medicine that I'm dying to give to pregnant ladies. 691 00:37:37,731 --> 00:37:40,101 And this is an area that interests me as well for research. 692 00:37:40,131 --> 00:37:44,151 'cause I also think that your second generation anti-psychotics. 693 00:37:44,301 --> 00:37:48,141 You know, olanzapine being my favorite as, as I'll keep saying here today. 694 00:37:48,526 --> 00:37:53,176 I think this is an area where we can have more success in treating these 695 00:37:53,176 --> 00:37:57,676 patients if they've got a mixture of morning sickness, CHS or cannabis 696 00:37:57,676 --> 00:37:59,916 hyperemesis and hyperemesis gravidarum. 697 00:38:00,106 --> 00:38:03,673 It's just a, patient population where you've gotta be as supportive as you can. 698 00:38:03,673 --> 00:38:06,553 You've gotta really encourage them that if they're getting vomiting and 699 00:38:06,553 --> 00:38:09,783 it's getting worse with using THC products, then they've really gotta 700 00:38:09,783 --> 00:38:12,078 try to cut it out and it's gonna get better, but it's gonna take time. 701 00:38:12,778 --> 00:38:13,068 Sam : Yeah. 702 00:38:13,768 --> 00:38:17,458 And the cannabinoids in this population are not benign. 703 00:38:17,488 --> 00:38:19,708 There are adverse effects on the fetus. 704 00:38:19,708 --> 00:38:25,138 Things like low birth weight and perinatal neonatal intensive care unit admissions 705 00:38:25,328 --> 00:38:29,558 are higher in the category of patients who use cannabis regularly during pregnancy. 706 00:38:29,558 --> 00:38:32,734 So it doesn't come without a cost for sure, and definitely is going 707 00:38:32,734 --> 00:38:34,174 to be a challenging conversation. 708 00:38:34,444 --> 00:38:35,074 Absolutely. 709 00:38:35,424 --> 00:38:38,844 And that brings us to the five things that will change your practice. 710 00:38:38,844 --> 00:38:41,994 One of those summary sections at the end of each issue. 711 00:38:41,994 --> 00:38:47,184 So one is eliciting a history of cannabis use regardless of the age, you just 712 00:38:47,184 --> 00:38:50,754 gotta ask, especially in that pediatric population as we already discussed. 713 00:38:50,994 --> 00:38:55,764 Second is know the limitations of your testing so you can get the testing. 714 00:38:55,764 --> 00:38:59,574 But the drug test can be false positive, which can come with significant 715 00:38:59,574 --> 00:39:01,164 repercussions if it's a child. 716 00:39:01,344 --> 00:39:04,374 So ask about those false positive medications. 717 00:39:04,614 --> 00:39:08,754 Or if it's negative and you still suspect it, just know it's not likely 718 00:39:08,754 --> 00:39:10,104 to show up on your drug screen. 719 00:39:10,804 --> 00:39:13,924 Number three, consider an ECG, especially if you're gonna end up 720 00:39:13,924 --> 00:39:17,554 using some kind of butyrophenone or antipsychotic medication that's also 721 00:39:17,554 --> 00:39:19,264 known to affect the QT interval. 722 00:39:19,484 --> 00:39:23,384 Number four, laboratory testing may be required. 723 00:39:23,384 --> 00:39:26,175 So look back at their previous visits. 724 00:39:26,175 --> 00:39:29,565 If you're considering something like rhabdo or renal injury, you have to test 725 00:39:29,565 --> 00:39:33,770 for those things and know that there are some cardiac complications that can occur. 726 00:39:33,860 --> 00:39:36,050 So you may need to also obtain that testing. 727 00:39:36,500 --> 00:39:40,520 And lastly, consider those butyrophenones, whether that's Haloperidol or droperidol 728 00:39:40,520 --> 00:39:43,670 or in your case, your favorite Olanzapine. 729 00:39:43,830 --> 00:39:47,280 Just make sure that you are talking to the patient about it to understand 730 00:39:47,280 --> 00:39:50,650 their previous, exposures to the medications, if they've had any side 731 00:39:50,650 --> 00:39:52,510 effects, address those ahead of time. 732 00:39:52,760 --> 00:39:56,970 And know that this is the extent of what you can manage in the ED. 733 00:39:57,000 --> 00:39:59,820 So if you try this medication category and you still don't have 734 00:39:59,820 --> 00:40:02,340 them under control, they just need to be admitted at the hospital. 735 00:40:02,490 --> 00:40:03,360 And that's okay. 736 00:40:03,990 --> 00:40:06,990 That's not some kind of personal failure on our behalf. 737 00:40:07,075 --> 00:40:09,480 It's just, Hey, we tried everything we had, we threw the kitchen 738 00:40:09,480 --> 00:40:10,650 sink at them and it didn't work. 739 00:40:10,830 --> 00:40:15,010 And sometimes people need longer stays in the hospital before we can 740 00:40:15,010 --> 00:40:16,150 get their symptoms under control. 741 00:40:16,850 --> 00:40:17,070 T.R. Eckler: Yep. 742 00:40:17,175 --> 00:40:22,185 You're fighting against a wide variety of chemicals and a wide variety of dosages, 743 00:40:22,185 --> 00:40:26,415 and you just gotta keep an open mind and keep trying things and keep trying to do 744 00:40:26,415 --> 00:40:30,825 what's best for the patient because it's a really challenging area and the more 745 00:40:30,825 --> 00:40:34,845 you approach it kind of slowly and just keep trying to build your understanding of 746 00:40:34,845 --> 00:40:37,635 what's causing the patient's symptoms, the better you're gonna do for these people. 747 00:40:38,335 --> 00:40:40,135 Sam : Couldn't have said it better myself, ladies and gentlemen. 748 00:40:40,135 --> 00:40:41,665 And that is the end. 749 00:40:41,665 --> 00:40:44,710 This is the emergency medicine practice issue for December, 750 00:40:44,710 --> 00:40:48,565 2025, diagnosis and management of cannabis related emergencies. 751 00:40:48,565 --> 00:40:52,405 If you're a subscriber, go to eb medicine.net, take the CME test and 752 00:40:52,405 --> 00:40:55,495 claim your CME and until next time. 753 00:40:55,565 --> 00:40:59,495 Have a happy holidays, a Merry Christmas, a wonderful New Year, 754 00:40:59,765 --> 00:41:02,495 and we will see you guys in 2026. 755 00:41:03,195 --> 00:41:03,825 T.R. Eckler: Enjoy the trees. 756 00:41:03,885 --> 00:41:04,610 Don't smoke 'em. 757 00:41:05,446 --> 00:41:07,266 Sam : And that's a wrap for this month's episode. 758 00:41:07,306 --> 00:41:09,886 I hope you found it educational and informative. 759 00:41:10,086 --> 00:41:14,946 Don't forget to go to ebmedicine.net to read the article and claim your CME. 760 00:41:15,116 --> 00:41:18,306 And of course, check out all three of the journals and the multitude of 761 00:41:18,306 --> 00:41:22,666 resources available to you, both for emergency medicine, pediatric emergency 762 00:41:22,666 --> 00:41:24,936 medicine, and evidence based urgent care. 763 00:41:25,246 --> 00:41:27,216 Until next time, everyone be safe.