T.R. Eckler: The AI Soon we'll be like, Hey, patient uh, has
vomited six times in bed eight.
Have you considered cannabis hyperemesis in your diagnostic?
Sam : Hi everyone, and welcome to another episode of EMPlify
I'm your host, Sam Ashoo.
Before we dive into this month's episode, I want to say thank you for joining us.
I sincerely hope that you find it to be helpful and informative for your
clinical practice, and I want to remind you that you can go to ebmedicine.net
where you will find our three journals, Emergency Medicine Practice, Pediatric
Emergency Medicine Practice, and Evidence Based Urgent Care, and a multitude of
other resources, like the EKG course, the laceration course, interactive
clinical pathways, just tons of information to support your practice
and help you in your patient care.
And now, let's jump into this month's episode.
Welcome back ladies and gentlemen, to another episode of Emplify.
I am one of your hosts, Sam Ashoo, in on the other side of the microphone.
T.R. Eckler: Dr. TR Eckler, I come from Colorado.
I've seen a lot of marijuana.
Sam : As he says, apparently they have some of this stuff
in Colorado, so he says,
T.R. Eckler: I, I use that as my trading card with these patients
because I would tell you, it immediately does score points.
They're like, oh, oh, you, you're from Colorado.
You know what you're talking about?
I'm like,
yeah, I've seen a lot of this.
Sam : instant street cred.
Okay, well that's a great introduction to what we're talking about today,
which is the diagnosis and management of cannabis related emergencies.
A very important topic and one we see very often in the emergency
department, and if you work in an ED.
You know exactly what I'm talking about.
This is the December, 2025 issue of emergency medicine practice authored
by Dr. Williams and Dr. Byram.
And again, a very good job trying to review, I would say, the paucity
of evidence about this condition.
The authors did a good job of talking about not just cannabis hyperemesis
syndrome, but all of the issues around cannabis and why it's current federal
illegal status hinders clinical research.
And so that's kind of one of the major contributors to why we have
very little information about this.
But they did summarize what we do know which I think was a pretty good review.
The issue itself covers all of the things that are cannabis related, including
even a little bit of a description of our legal status here in the United States.
So 48 states including the District of Columbia and three
other territories allow the use of cannabis for medicinal purposes.
So, you know, most of the country in that scenario is accepting of
marijuana use for medicinal purposes.
There are eight states that allow only a specific type
of the high potency products.
And then there are 24 other states that will allow for non medicinal uses as well.
So it's very much a hodgepodge of different laws across state borders.
And if you're listening and you're not in our state of Florida, you
probably have a completely different legal scenario to deal with.
Interesting that because of the acceptance for medicinal and non
medicinal uses, we've seen an increase in ED visits all over the country.
The substance Abuse and Mental Health Services Administration has a report
called Dawn or the Drug Abuse Warning Network, which estimates that there's
about a million cannabis related emergency department visits that occurred last year,
which is not an insignificant number.
So a million visits with some kind of cannabis related problem.
Most of them occurring in the younger population, 26 to 44.
Especially in that kinda young teen, early twenties predominating and really
covering a wide spectrum of presentations.
Everything from nausea and vomiting to altered mental status
and acute psychosis to you know, people with paranoid delusions.
And so we see all kinds of things, and it primarily comes
from the fact that it's not just.
The plant derivative that we see, but also people reacting to the synthetics
and the synthetics, depending on their chemical compound, may have
nothing plant derived in them.
And because of that, they're not necessarily illegal.
They may not be banned substances and they may be available at your local vape
shop under a bunch of different names.
And that causes us problems in the ED because people come in saying,
no, I'm not using any drugs.
I have this perfectly legitimate thing, I buy over the counter
and I smoke it every single day.
That's when we discover, oh, okay, you're using some kind of synthetic
that is trying to trigger these same receptors and causing you these problems.
And that doesn't show up on a drug stream.
So it's a very heterogeneous population of patients, but also of substances that
people put under the blanket of cannabis.
T.R. Eckler: This has been one of the defining kind of, you know, just
increasing area of prevalence and treatment that's defined my career since
I really started residency in 2012.
We used to see a lot of synthetic cannabis in New York City because when
I was there, marijuana was not legal and it was enough to make us want to
advocate for better regulation and even legalization to get away from the
synthetics because you were, as you said, you're talking about spraying some sort
of chemical onto some sort of plant to make it look more natural and so you can
burn it and smoke it, so people think it's something natural they're getting.
But it's really just like some sort of herb or plant that's been sprayed and
then, you know, then they go and smoke it.
And we used to see seizures, we used to see respiratory failure.
It was really something that was really challenging for us.
'cause you just didn't know if and when they were gonna get better
or if they needed to have, you know, more airway protection,
more intensive things to be done.
And it was a big drain on resources.
And then to move from there to practicing Colorado after they had legalized.
I saw so much use and I saw both the upsides and the downsides and
just all the different ways that it makes people very, very sick.
I have stories for days about this, but I think that the challenge is just
the range of patients that it affects.
You're talking about big ingestions in children all the way up to older people
that think that they know what THC does to them, and then they get into some of
the newer products that are out there that have way more THC than they ever
experienced in their lives, and they come in with really severe symptoms.
So it affects everybody and I think it's something that we need more research and
as good a regulation as we could get to make this as safe as possible for people.
Sam : Yeah, absolutely.
And just to muddy the waters even more, there are some cannabis related
products that are FDA approved.
So you can find cannabis related products that are FDA approved for anorexia
that's associated with HIV or AIDS or Chemotherapy induced nausea and vomiting
or intractable seizures in children.
Those are some of the examples where there are FDA products that
have approval even for intractable spasticity from multiple sclerosis.
But that's where it stops.
And so that's where the evidence stops because those are the only
things that have FDA approval.
I thought the authors did a, very good job of describing what we know
about the physiology of cannabis and how it affects the body.
You know, they detailed in there a good description of cannabinoid one and
cannabinoid two receptors and that the one receptors are found mostly in the,
central nervous system and two receptors can be found really almost anywhere, but
primarily in the immune system, which kinda is a pathophysiological mechanism
for its anti-inflammatory effects.
But the CB one or the cannabinoid one receptors in the nervous system
are the ones where we're gonna find the majority of our clinical effects.
And those are the things like everything from increased excitation all the
way up to seizures, to modulation of dopamine and acetylcholine and glutamate
and serotonin through GABA receptors.
And so it has a, plethora of effects, which ironically is kind of moderated
by the plant derived marijuana.
The original thing that people used to grow and use in, multiple countries
and cultures and now is in overdrive with synthetic cannabinoids, which
are hundreds of times more potent and providing excess stimulation at those
receptors far beyond what the organic or plant derived chemicals used to do.
And that's where we see the other symptoms.
So most people think of marijuana as something that's gonna kind of relax you,
calm you, you know, sedate you, and yet we're seeing exactly the opposite effect
from the synthetics or even the high potency plants because you're just getting
way overstimulation of these receptors.
And then with chronic users, we get a whole nother different pathophysiology
where these receptors can get downregulated and then if people stop,
they can get withdrawal symptoms.
If people continue to use, they can get a whole host of other symptoms that are
kind of thought of as things that you would normally use marijuana to treat.
So persistent nausea and vomiting is something that I'm constantly discussing
with people who use marijuana on the regular because they think, oh, well this
is something my marijuana would cure.
There's no way it's the cause for these symptoms.
And then we have to go down this whole explanation of why that's
not correct and what we know about cannabis hyperemesis syndrome.
So yeah, I think the authors did a great job of just describing that
pathophysiology and at the very least, describing the complexity
of how all of this fits together.
T.R. Eckler: And the biggest struggle is just there's so many different products
that are aimed at like targeting this pathway and you just can't test for it.
It's not like one drug, like alcohol or you know, nicotine where you
at least know what the drug is.
And as they make certain ones illegal, other ones pop up.
So it's a very wild west time in this area and I think that's why it's really
important to talk about it and advocate really strongly for more research
. Sam : Yeah.
Yeah, absolutely.
And talk to your children about it, because many of these things are
marketed at the younger population, so they just need to be aware that
just 'cause it's available at your local vape shop does not make it safe.
All right.
Let's talk about a couple of helpful resources here before we
jump into the clinical effects.
There is a table on page five which discusses all of the different routes
that these are now available in, which is something that's new in the past decade.
So it used to be you had to smoke it and that was the only
route to inhale it into your body.
But now there are ways to ingest it in capsules and tablets
and even ingestible oils.
There's transmucosal ways.
So, you know, sublingual oral tinctures and sprays as you mentioned.
And some hard candies that you can suck on.
There are even rectal suppositories for methods of delivery.
And then there's topical transdermal, so creams, gels, patches, and oils.
And really the sky is the limit.
If there is some way for your body to absorb it.
There is a product out there that's available in that formulation.
So you have to ask that piece in your history and just say, Hey, you know,
are you using any of these products in any one of these delivery mechanisms?
T.R. Eckler: And also like exactly what is your delivery mechanism.
We had a lot of people using wax and very like, concentrated oils.
And they would basically use an acetylene torch to burn them and vaporize them and
then they would inhale them that way.
And we had a few patients in Colorado who got Pneumomediastinum from basically,
you know, popping a hole in their airway from this superheated cannabis wax.
So it's important to ask that 'cause it gives you a bigger sense of
kind of what their risk level is.
And also if they're gonna show you something about inflammation in
your lungs, like some kind of a vape lung, you can get that from
some of these products as well.
Sam : Great points.
And then when we talk about the drug effects, the author's broke this down
into multiple categories based on systems.
So the psychiatric effects being the biggest one, and again, ironically
symptoms occur that we think of as symptoms you would treat with cannabis.
So things like anxiety and panic attacks and paranoia and acute psychosis
with hallucinations and delusions.
These are symptoms of acute intoxication, especially with the
synthetics that people can present with.
And it can be very aggressive.
It can be severely agitated all the way down to the depressive
and comatose and unresponsive.
That spectrum is very, very wide, but all of those psychiatric effects
in acute intoxication can be seen.
And then there are the cardiovascular effects, which I thought was
exceptionally enlightening here, you know, obviously there's tachycardia.
You can get some hemodynamic instability, hypertension or postural
hypotension or, interestingly, a decrease in your anginal threshold.
There was actually one article cited by the authors that showed a fivefold
increase in the risk of MI in the first hour of cannabis use, which
eventually waned as you kind of continued using it beyond the first hour.
But if you have any kind of propensity to coronary artery disease or any
risk factors, now all of a sudden you've quintupled that risk in the
first hour by smoking marijuana.
Which again, is not something that's popularly advertised, but
something we need to be aware of.
There was also a discussion about the synthetics affecting QT syndrome.
So you can lengthen your QT on your EKG and give you a propensity to arrhythmias
and ventricular dysrhythmias because you're smoking marijuana or using one
of these synthetic drugs, which again, is not something we think about, but is
important because if we're going to be treating them and we're using something
else that will also prolong their qt we're just kind of adding these effects up.
The pulmonary effects includes things like bronchospasm and
exacerbating your underlying asthma or COPD or pulmonary disease.
There are renal effects.
You can get acute tubular necrosis or acute interstitial nephritis from
the drugs, especially the synthetic versions, and you can get rhabdomyolysis.
And so there are all kinds of effects on every single system.
The metabolic effects include everything from hypothermia
to hypoglycemia, hypokalemia, hyponatremia, and metabolic acidosis.
You can get dry mouth and dental effects, and you can get even ocular effects.
And so I say virtually every system in your body is affected by it.
The receptors are everywhere, even though they're primarily in the central
nervous system, no system goes untouched.
And then there's a description of cannabinoid hyperemesis syndrome.
So if you're not familiar with it, cannabinoid hyperemesis syndrome
is something that occurs in chronic users and begins as nausea.
Poor appetite, maybe some anorexia progresses to persistent severe
nausea, vomiting, and can come with significant abdominal pain and retching
that can become intractable and end them up in an emergency department.
And is often really difficult to treat because people get resistant to the
typical things that we use for nausea and vomiting, and they require higher
and higher doses, and each time they have a flare, it's more severe and
oftentimes, there's lots of discussions that occur trying to convince someone
that it's actually the cannabis use that's causing this problem.
And so they present with a history of multiple ED visits, multiple specialty
visits with gastroenterologists, multiple procedures performed
without an underlying etiology.
It can be very complicated to treat but it does come with three phases.
You get that prodrome where you have lots of nausea, and then you get the
hyperemesis phase, which comes with a lot of nausea and vomiting and persistent
vomiting with some abdominal pain.
And then hopefully you get that recovery after you've been hydrated
and treated if the nausea is stopped back and then into your normal state.
And if you're a chronic user, then you're just gonna cycle through this
again and again and again and again.
And the typical nausea and vomiting, that persistent nausea
and vomiting phase, phase two can last anywhere from 24 to 48 hours.
So we're usually seeing people in the ED who have tried a bunch
of things at home because they've had this happen a bunch of times.
And interestingly, one of the pathognomonic things about the syndrome
is that people will eventually figure out either through Google searches or
experimentation on their own, that there are some things they can do at home to
try and help with the nausea and vomiting and hot showers happens to be one of them.
And so that is one of the historical questions we can ask is, Hey, have
you tried treating this at home?
What works for you at home?
And if they talk about hot showers or if you probe them with that question
and they say, yes, that can be indicative of this particular syndrome.
T.R. Eckler: I think it's always good to ask them too, like, does you know
any kind of THC use trigger this?
Or was there an inciting event?
I find that a lot of times people that aren't necessarily big THC users will use
someone else's vape or inhaler type device and they'll get a very, very high dose of
THC from like a, you know, prescription grade device or something like that.
And all of a sudden they get a much higher dose than they've ever been exposed to.
And that triggers them to go into acute CHS and then, if that, or if
their use starts to cause them to have this nausea and the vomiting.
I think that gives you a key that some of your kind of typical nausea
medicines aren't gonna work and you need to try something different.
Sam : Yeah.
Yep.
And then there is a withdrawal syndrome.
It's been described especially in the chronic users that that this withdrawal
can occur anywhere from 24 to 72 hours after last use, and can last anywhere
from two to six days, and can come with really a lot of irritability, anxiety,
depression, restlessness, poor sleep, or lack of sleep, tremors, muscle twitching.
GI distress and headache, and anywhere from, at least in the limited data
we have, up to 73% of individuals attempting to stop cannabis will
experience at least some of these, especially the sleep difficulty.
And so that may be the presenting symptom to the emergency department
and just makes it again, even more important to ask those questions.
If they're withdrawing from synthetic cannabinoids, there might be seizures,
psychosis, and delirium as well.
So just another plug that if you're using the synthetic cannabinoids, your
symptoms are going to be far exaggerated, far worse, whether that's on the
withdrawal side or the intoxication side.
T.R. Eckler: Yeah.
And if, someone's basically coming in with cannabis hyperemesis, you're gonna
have to try to convince them they need to stop using for a month to try to
allow their system to wash out and reset.
And I think that counseling them on, you know, how they can manage their symptoms
at home, counseling them on the withdrawal period and the fact that it's gonna be bad
for maybe two or three days but then it'll start getting better, I think gives them
an idea of like what they're gonna have to get through to start getting better.
And it gives 'em a better timeline of where they're at.
Sam : Yeah.
And the differential diagnosis for it is very big because it's persistent
nausea and vomiting and abdominal pain.
And so you could think of, you know, life-threatening things as
they have headache associated.
They could have something in their brain, a central nervous system lesion.
They're gonna have electrolyte abnormalities, low glucose, low
sodium, low potassium meningitis and encephalitis can certainly cause
headaches and altered mental status.
Intoxication with a bunch of other substances may also be occurring.
And so, you know, especially if they're buying it off the street,
you don't know what's mixed with it.
So polysubstance ingestion is a big one.
Sympathomimetic intoxication.
And then there are gonna be psychiatric things like acute psychosis.
If they have a history of schizophrenia and they're a chronic user and now
they're using the synthetics, it can either exacerbate those symptoms
or it can be the underlying cause and things like panic attacks.
And so there's a lot of things to keep in mind in your differential.
And that doesn't even get into the differential of just intractable
vomiting and abdominal pain, which includes everything from, you know,
like cyclic vomiting to you know, bowel obstruction and appendicitis and
surgical issues and gallbladder problems.
And this is part of the reason why people are hard to convince that it's a cannabis
related issue because there's so many other things and you know the chances that
we are gonna find something, even though it may not be the cause, but something on
your CT abdomen and labs are pretty high.
You know your sodium's gonna be low, your potassium's gonna be
low, you're gonna be dehydrated.
You might have some gallstones.
It may be completely unrelated, but you might have some gallstones.
And so I have seen people who go down that entire path, get their
gallbladder removed, end up being diagnosed with functional abdominal
pain, nobody understands why, and end up on some other meds.
And then finally, someone asks about the marijuana use and they go, oh
no, there's no way that could be it.
And I go, Hey, you have tried everything else.
You've had organs removed.
It might be time to give the marijuana a break for about six weeks
and see if your symptoms go away.
When it comes to the pre-hospital care, really it's just what we
always rely on our paramedics for.
So asking that history, looking for pill bottles, trying to help us figure out
if there's been some other ingestion, especially if there's altered mental
status when it comes to the ED history, I rely a lot on family members or
anyone else who's with the patient.
Because the patient sometimes isn't able to answer questions, especially
if there's altered mentation, but sometimes they're not willing to either.
You know, family members are way more willing to say, oh yeah, people have
tried to tell this person to stop using this product, this spice product,
or this over the counter synthetic.
And the person won't listen.
Or, yes, they've had this conversation multiple times before,
but they stopped for a while and now they've gone back to it.
You know, that kind of history is very, very, very important.
When you're looking at the physical examination, it's gonna be, you know,
vital signs, trying to narrow your differential, looking for abdominal
tenderness, trying to understand what exactly is the underlying cause for
their persistent nausea and vomiting.
And then we get into diagnostics.
And really this depends heavily on Where they are in their presentation spectrum.
So is this their first time ever?
They're gonna undergo a lot of testing.
If it's not their first time and this is their 150th visit and they just had a
visit yesterday and they've already had 8 million CT scans and a bunch of labs, then
you do have to take that into account.
And so when we talk about our diagnostic studies, I think the spectrum is
large, but you do have to take that with a grain of salt that, yeah.
They've probably already had most of this done at some point.
The most important thing to keep in mind is that your drug test is mostly
unreliable if it's positive, okay?
But there are some false positives, especially things oddly enough
like ibuprofen and pantoprazole, which can give you false positives
on your drug screen for marijuana.
Lamotrigine can do it.
Sustiva can do it if they have a history of HIV that can also give you
a false positive on the drug screen.
But more importantly, they may not test positive at all.
If they're on a synthetic, they're gonna have no registration of that
drug on the drug screen at all.
So you really can't rely on that test very much.
When it comes to laboratory examination, you definitely wanna look
for coingestants and that includes things like Tylenol and aspirin.
And you wanna consider, especially if they're having chest pain or cardiac
related abnormalities, that you might need a troponin, you might need to look for
rhabdo, you might need to get an EKG and get a chest x-ray and go down that route.
They can get related myocarditis, pericarditis, MI. And if they're
altered, it can be hard to elicit that history and if they're tachycardic.
These are all reasons to be liberal in your testing.
T.R. Eckler: I would tell you, all these people get EKGs from me.
'cause I wanna know where their QT starts and their QRS is because almost
all the medicines we're gonna pick are gonna have some effect on that QTC.
So I think that's one thing that all these people are getting.
And then I think I'm more inclined after this article to chase the troponin
in the CK because I think that we're seeing more, and especially in some of
the synthetic stuff, some of the sicker looking people, that's more something
that I'm gonna wanna make sure is okay.
But I would tell you the hardest thing about these people is
they all tend to have a pretty significant degree of leukocytosis.
And it's hard just because you know you're looking at someone that's unwell.
And they're vomiting a bunch and you're like they had a CT, but
they've got this white count.
And I would tell you that in practice, I've seen so many of these people with
legitimate white counts that never really have much on imaging or things like that.
So I think to your point, if they have not had imaging, then I'm not opposed to that.
But if they've already had, you know, the ultrasound and the CT in the last
month or two I am not regularly imaging these people when they come in, if
they're young and healthy and don't have a history of bowel obstruction or
anything, because most often treatment tends to resolve their symptoms.
And then I can basically say, all right, like if treatment's not working, then
I start to think more about imaging.
But I think a lot of times that they're gonna have a white count,
they're gonna look pretty unwell until you start to turn around.
Sam : Yeah.
Yeah.
And this is a great opportunity for some of that shared decision making
where you ask them, Hey, you know, is this similar to your prior visit?
Yes, it is.
Okay.
What worked last time?
Do you have any idea what's triggering this?
And if it's the same trigger again and the same medicine works, you
know, you've had 50 abdominal CT scans, which haven't shown anything.
I'm trying to save you some radiation.
What do you think about not getting the scan today?
And oftentimes they'll be like, oh, I don't even want the scan.
You know, I just feel like I'm always getting it 'cause I'm coming to the ED,
but I don't think they think I need that.
I just want x, Y or Z, you know, at that point.
So a good conversation to have.
There are some recommended first line treatments that the authors mentioned.
And again, we have a paucity of evidence, so what are we treating?
We're treating clinical symptoms.
So if they're agitated, tachycardic, having increased anxiety, you can
use benzodiazepines to manage those kind of neuropsychiatric effects.
There is the side effect of helping with some nausea with the benzodiazepines.
So yes, there is a role for use of benzodiazepines and then
you're gonna use antiemetics.
You can start with things that are first line for all of us, like
ondansetron is a purely antiemetic.
You can use something that's a pro motility agent as well,
like metoclopramide and mix and match some of those things.
You are gonna want to get a baseline EKG, especially if you end up having
to progress to second line agents.
And these are agents that are gonna affect multiple receptors like the
butyrophenones, like Haldol or droperidol.
They may have QT effects, so it's helpful to get the ECG.
But more importantly, they do have some sedation effects as well for some people.
And in some cases experimenting with these, the patients will get
to know, okay, this works for me.
This doesn't work for me.
And if it doesn't work for them, it's important to ask why, because it may
just be a side effect of the medication.
So, you know, dystonia is one of those.
I think you mentioned that you've seen lots of patients who kind of
will list one of these medicines as an allergy, when actually they
just had a dystonic reaction.
T.R. Eckler: And I think that in these kind of patients, to what you said,
what has worked for them in the past and what hasn't worked is important.
Because if you're gonna spend, you know, medicine that could prolong their QTC
and you're choosing between Zofran, Phenergan, Haldol, or triperidol I think
that it's really important for if they tell you, look, Zofran and phenergan don't
work for me, then don't give it to 'em.
Like if it's not working for them, for this start into a Haldol or droperidol.
In my practice, I'm using more and more Zyprexa because I find that it
seems safer overall as a medication when compared to the other two.
There's less dystonic reactions and it lasts longer.
So I find that patients get more relief.
It also offers a dissolvable tablet that they can go home with.
I'm not advocating for them to get large quantities of it, but I think
that you then give them a pathway of getting through that 24, 48, 72 hours
of really the bad part of the cannabis hyperemesis severe vomiting phase.
I think that's really important when you think about trying to
prevent bouncebacks to the ER.
But I think that these medicines, if you can really clearly have a sense
that this is cannabis hyperemesis.
And you go to something like a Haldol, a droperidol or a Zyprexa, their nausea
and vomiting gets better, their pain gets better, and they have like an obvious
sense of relief when you walk in the room where they're significantly better.
And I like starting at smaller doses and gradually coming up 'cause you hit the
sweet spot for a lot of patients and you say, Hey, do you feel good enough now?
Or do you think you want a little bit more?
And I find that they are great judge of when they think they need a little
more and they can kind of balance the sedating side effects of the
medicine versus just their horrible, uncontrolled vomiting and nausea sense.
Sam : Yeah.
And if you're gonna use one of these butyrophenones the authors also did
a good job of, you know, signaling that it can take about an hour from
the time you give a dose to the time that they're gonna have some relief.
So It's not as quick as Ondansetron or even metoclopramide when you're
giving it for nausea and vomiting.
And if they're retching, it's just like, you know, you kind of have to temper
the fact that you hear it in that room.
And you might get the nurses that going, okay, they're still retching,
they're still retching, and go, okay, we just gotta give it a little time.
It hasn't been an hour since the last dose, or it hasn't been enough
time for this to really take effect.
and that some of these medicines are sedating, so if you're giving them
benzos, if you're giving them these butyrophenones, if they've already had
a dose or two of an anti-emetic as well, you just gotta be careful that you're
stacking sedating medications as well.
T.R. Eckler: And that's why I'm trying to keep it simple and going straight
to, you know, the medicines like Haldol and droperidol and Zyprexa because I
would like to be using a medicine that I think is gonna be most effective if I'm
gonna have those sedating side effects and not basically be limited by the
other medicines sedation as to giving them more of what I think they need.
Sam : Yeah.
Yeah.
And totally okay to have that discussion with the patient and say,
Hey, these have dystonic side effects.
So if you get to the point where you're having some spasms, muscle
twitching, you feel a little bit more rigid at home, just take some Benadryl.
Here's the dosing, here's how often you can take it and just anticipate
this is not an allergic reaction.
This is a normal side effect of the medicine, and all I'm trying
to do is keep you from going home and coming right back again.
'cause the medicine's worn off or something of that sort.
So, there is some evidence for capsaicin.
So capsaicin is a topical agent that can be given over the abdomen.
And there is a pathophysiological mechanism described by the authors
where it triggers these receptors that are generally kinda capped
out already from marijuana.
And now you're trying to just completely overwhelm these receptors
and reduce the nausea and vomiting.
And strangely enough, capsaicin does it.
It comes in topical gels and creams and even patches that can be applied usually
over the abdominal wall, anywhere from 0.025%, all the way up to 8% for patches.
And some people will experience an improvement in their symptoms.
Some people have already tried this at home before they've come in.
some people, we experiment with it in the ED because we've kind of run out
of our options and the only option left is to admit 'em to the hospital.
And I go, okay, well, why not?
What's the downside to trying this?
So it's okay to experiment with some.
Some will have relief as soon as 30 to 45 minutes from the application.
If it hasn't worked at that point, it's probably not going to work.
T.R. Eckler: We did it in rural Colorado a bunch because you were kind
of debating between like admitting the patient and transferring the
patient or you know, what you could do.
And I would say that mixing this and, other medicines, I saw some
efficacy to it, but it's also pretty uncomfortable for the patients.
So I don't think it, really met my hope of trying to do no harm as
I was doing good to the patients.
'cause they're kind of like sitting there wincing, going, I feel a little better.
But like, they don't look more comfortable.
They just look like
Sam : I'm distracted.
T.R. Eckler: I am distracted.
Sam : My abdomen's burning like crazy right now.
Yeah, totally.
And another thing to keep in mind is, I have seen physicians kind of punitively go
slow with the treatment or undertreat the persistent nausea and vomiting, thinking
there's some kind of malingering component to it because the person's also asking for
pain medicine or something of that sort.
And you just have to be careful because they can get complications
from persistent nausea and vomiting, you know, Boerhaave syndrome.
They can get injuries to their esophagus.
They can aspirate, they can get pneumonitis, they can have
all these other problems that come from persistent symptoms.
And the safer side is to treat them for what they're actually presenting
with and try and get it under control as quickly as possible.
T.R. Eckler: I feel like you, you captured it perfectly earlier when you just hear
that person, like in the ER that vomits and vomits again and vomits again.
I feel like if you vomit, like three or four times in like
five minutes and I can hear it.
I'm walking over to your room to be like, hi, have you ever thought about
this could be cannabis hyperemesis.
Sam : Exactly.
T.R. Eckler: feel like I have to slow roll the questions a little bit, and
honestly there's some aspect of my practice it's like this where I'll ask
'em what they've taken and they'll already have tried Zofran or something at home
and I'll give them an anti-psychotic and they're like, wow, I feel so much better.
And I'm like, Hmm, this is probably cannabis hyperemesis then.
And then they kind of go.
Oh, and it's, a little bit the chicken before the egg, but I think
that, you know, it, gives them a sense of, ah, yeah, that makes sense.
If this is what makes me better and that's what you think it is.
Like, you know, there's no accusatory piece of it.
It's just, Hey, this is what this works really good on.
Sam : Yeah I put this in the sense and sounds of the ER category right there.
There's a smell to c diff, there's a smell to pseudomonas, there's a smell to melana.
There is a sound to cannabis hyperemesis syndrome.
You just hear that retching and you go, yeah, we don't usually
get this kind of retching, even in bowel obstruction like this.
This is very significant and very classic for this disorder.
Which is interesting.
I don't, it'll be one thing to study really like, you know, the
acoustic diagnostic sensitivity for cannabis hyperemesis syndrome.
T.R. Eckler: Don't worry.
The AI Soon we'll be like, Hey, patient uh, has vomited six times in bed.
Eight.
Have you considered cannabis hyperemesis in your diagnostic?
Sam : That's right.
There was a good discussion there of some special populations, and of
course, pediatrics is one of them because, you know, again, they're
getting marketed to children.
And the authors cited a survey which found that about 14% were children
between 12 and 17 years of age for people who were using marijuana.
And in that same age group, 11% reported cannabis use in the last year,
6% reported cannabis use in the last month in that age range, 12 to 17.
And it's not an insignificant number of ED visits there.
Making about 15% of the population of this category that are coming to the ER are
gonna be children, and you have to ask.
And then you have to be careful about the testing and also what
you do with that information.
You know, a child who tests positive for marijuana and is getting exposed
at home or got into something, this is a reportable incident and they can
end up getting taken out of that home.
And I'm not saying you shouldn't test because of that, but just
understand that there are multiple layers to this kind of visit.
So treat the patient, get your testing done, but then understand you also
have reporting responsibilities beyond that, if we're talking about a child.
T.R. Eckler: Just the prevalence of gummy candy type THC edibles are so
high that on a regular basis we're either seeing children in the ER or
having them honestly transferred in to be admitted to our PICU 'cause
they're essentially like unresponsive.
And I find that this is a good time where you do a full workup on these kids.
But I think a drug screen is helpful because it's nice if you get a
positive drug screen that's clearly THC to stop, you know, a lumbar
puncture or some of the other things that start to get talked about.
So I, think that getting a drug screen is a good thing to get.
I don't think you should hang your hat on it diagnostically here, given the age
of synthetics and all the other things.
But I still think it's worth having because especially in these young kids,
when everyone will swear up and down, there's no way it could have happened.
You know, it is just something where it all of a sudden, like an hour or
two later, they come up with, oh yeah, that cousin came over, or this or that.
They always find a scapegoat in the family to blame it on, and I think that's
the thing where you've just gotta, you know, always keep an open mind to that.
It's just one of these things that in pediatric populations,
there's so much access to it.
I try to make it as blame-free and kind of, you know, we're not, we're just
here to take care of you and your child.
We're not here to like immediately call CPS or anything else.
Like Colorado CPS was generally encouraging us not to call 'em about
pediatric ingestions because the bandwidth that they had was reasonable for a lot
of things, but it wasn't gonna cover every time a kid got into an edible
. Sam : Yeah, yeah.
Well, and I can understand in Colorado where it's legal, but at least you
know, in, other states, you just gotta be careful, right, know what your
mandatory reporting guidelines are and make sure you stick with them.
And interestingly, the children are more prone to coma and are more
prone to respiratory failure than the adults, which is kind of strange.
You know, up to 20% of children under 10 can get comatose from an ingestion, and
up to 6% of them can require mechanical ventilation, which is not something we
usually think about with cannabinoids.
So, it's not typically a respiratory depression kind of scenario.
And so you just gotta be super, super careful in that particular case that
you're doing your best for the child and looking for all those other causes
as well and not anchoring on something.
And then there are the second set of special populations of the authors brought
up, and that's our pregnant population, which again, very, very challenging.
If you've got somebody who's a chronic marijuana user and you're trying
to figure out are they throwing up because they're pregnant or are they
throwing up because they have chronic marijuana use, exceptionally difficult.
T.R. Eckler: Or just because you know now when you have morning
sickness, I think it is becoming more and more socially acceptable.
You have morning sickness.
Oh, you should take some kind of marijuana for that.
It will help with the nausea and the vomiting, and it's a
challenging thing to work through.
Is this morning sickness?
Is it, you know, hyperemesis gravidarum, or is it CHS?
I think that's another delicate area where you've gotta come in with no judgment.
You've gotta come in with asking about are there vitamins triggering this?
Is it foods that trigger this?
Like what is triggering it and are hot showers making it better?
And then you can kind of gradually try different things to see.
Now this isn't a patient population you wanna give Haldol and droperidol.
But if you look at in basically the OB literature.
If you go down through the hyperemesis gravidarum medication list, Thorazine
is really the bottom of that list.
And Thorazine is not a medicine that I'm dying to give to pregnant ladies.
And this is an area that interests me as well for research.
'cause I also think that your second generation anti-psychotics.
You know, olanzapine being my favorite as, as I'll keep saying here today.
I think this is an area where we can have more success in treating these
patients if they've got a mixture of morning sickness, CHS or cannabis
hyperemesis and hyperemesis gravidarum.
It's just a, patient population where you've gotta be as supportive as you can.
You've gotta really encourage them that if they're getting vomiting and
it's getting worse with using THC products, then they've really gotta
try to cut it out and it's gonna get better, but it's gonna take time.
Sam : Yeah.
And the cannabinoids in this population are not benign.
There are adverse effects on the fetus.
Things like low birth weight and perinatal neonatal intensive care unit admissions
are higher in the category of patients who use cannabis regularly during pregnancy.
So it doesn't come without a cost for sure, and definitely is going
to be a challenging conversation.
Absolutely.
And that brings us to the five things that will change your practice.
One of those summary sections at the end of each issue.
So one is eliciting a history of cannabis use regardless of the age, you just
gotta ask, especially in that pediatric population as we already discussed.
Second is know the limitations of your testing so you can get the testing.
But the drug test can be false positive, which can come with significant
repercussions if it's a child.
So ask about those false positive medications.
Or if it's negative and you still suspect it, just know it's not likely
to show up on your drug screen.
Number three, consider an ECG, especially if you're gonna end up
using some kind of butyrophenone or antipsychotic medication that's also
known to affect the QT interval.
Number four, laboratory testing may be required.
So look back at their previous visits.
If you're considering something like rhabdo or renal injury, you have to test
for those things and know that there are some cardiac complications that can occur.
So you may need to also obtain that testing.
And lastly, consider those butyrophenones, whether that's Haloperidol or droperidol
or in your case, your favorite Olanzapine.
Just make sure that you are talking to the patient about it to understand
their previous, exposures to the medications, if they've had any side
effects, address those ahead of time.
And know that this is the extent of what you can manage in the ED.
So if you try this medication category and you still don't have
them under control, they just need to be admitted at the hospital.
And that's okay.
That's not some kind of personal failure on our behalf.
It's just, Hey, we tried everything we had, we threw the kitchen
sink at them and it didn't work.
And sometimes people need longer stays in the hospital before we can
get their symptoms under control.
T.R. Eckler: Yep.
You're fighting against a wide variety of chemicals and a wide variety of dosages,
and you just gotta keep an open mind and keep trying things and keep trying to do
what's best for the patient because it's a really challenging area and the more
you approach it kind of slowly and just keep trying to build your understanding of
what's causing the patient's symptoms, the better you're gonna do for these people.
Sam : Couldn't have said it better myself, ladies and gentlemen.
And that is the end.
This is the emergency medicine practice issue for December,
2025, diagnosis and management of cannabis related emergencies.
If you're a subscriber, go to eb medicine.net, take the CME test and
claim your CME and until next time.
Have a happy holidays, a Merry Christmas, a wonderful New Year,
and we will see you guys in 2026.
T.R. Eckler: Enjoy the trees.
Don't smoke 'em.
Sam : And that's a wrap for this month's episode.
I hope you found it educational and informative.
Don't forget to go to ebmedicine.net to read the article and claim your CME.
And of course, check out all three of the journals and the multitude of
resources available to you, both for emergency medicine, pediatric emergency
medicine, and evidence based urgent care.
Until next time, everyone be safe.