Cannabinoid hyperemesis syndrome in two French emergency departments: a prospective cohort

Chronic cannabis use can be associated with uncontrollable vomiting and abdominal pain. Diagnostic criteria for cannabinoid hyperemesis syndrome (CHS) were defined in 2012 by Simonetto et al. The objectives of this study were to describe the prevalence of CHS, the patients' epidemiological characteristics, and to show the difficulties encountered in caring for these patients in emergency departments, the extent of health care and an unsuitable follow‐up in general practices. A prospective cohort of patients with CHS was recruited among a target population of patients leaving the adult emergency services of the Marseille hospitals Nord and La Timone between October 2017 and July 2018, with abdominal pain syndrome of unidentified etiology. Inclusion criteria for the CHS cohort were chronic cannabis use associated with nausea and vomiting. There were 48 patients included in the CHS cohort who took cannabis daily, in a target population of 2 848 patients (i.e. 1.6%). A hot shower was the most effective symptomatic treatment in 54.2% of cases. Patients suffering from CHS spent significantly more hours in emergency departments (11 vs. 6.5), and, on average, visits were more frequent (4.9 vs. 3). 20.3% of them were hospitalized to continue pain medication. Once out of hospital, follow‐up was limited, and weaning off cannabis, the only etiological treatment, was difficult to set up. Informing patients about CHS is essential, and a hot shower could be systematically proposed, thus limiting an unnecessary extent of health care. CHS is genuine, medical staff should be made aware of it in occupational training, and it should be seriously considered in health policies.     

A Case of Cannabinoid Hyperemesis Syndrome Caused by Synthetic Cannabinoids

Background

Cannabinoid hyperemesis syndrome (CHS) was initially described in 2004 and remains an under-recognized clinical entity that occurs in chronic heavy marijuana smokers.

Case Report

We describe the first report of CHS in an abuser of synthetic cannabinoids. CHS is thought to be caused by over-stimulation of the cannabinoid 1 receptor. The synthetic cannabinoids found in K2, Spice, and other commonly abused designer cannabinoids, including those used by our patient (JWH-018, JWH-073, JWH-122, AM-2201, and AM-694), are potent agonists of the cannabinoid 1 receptor.

Conclusion

Our report suggests that frequent habitual smoking of synthetic cannabinoids can cause cannabinoid hyperemesis syndrome.     

Alcohol use among young adults presenting to the emergency department

Objectives: To determine the prevalence of young ED patients at risk from hazardous alcohol consumption, to identify high‐risk patient subgroups and evaluate the feasibility of use of the Alcohol Use Disorders Identification Test (AUDIT) in this setting. Methods: We undertook a cross‐sectional survey of 336 ED patients aged 18–30 years, inclusive. All were breathalysed prior to self‐administering the AUDIT. A ‘positive’ AUDIT score (≥8) defined hazardous alcohol consumption. AUDIT scores were correlated with sex and trauma diagnosis. Results: One hundred and thirty‐one (39.0%, 95% confidence interval [CI] 33.8–44.5) patients were classified as AUDIT‐positive. Men were significantly more likely to be AUDIT‐positive (49%vs 23%, P < 0.001) and had significantly higher total AUDIT scores (P < 0.001) than women. Trauma patients were significantly more likely to be AUDIT‐positive (P < 0.001) and had significantly higher AUDIT scores than non‐trauma patients (P < 0.001). Of the six patients who recorded a positive breath alcohol reading, all were AUDIT‐positive. One hundred (76.3%, 95% CI 68.0–83.1) AUDIT‐positive patients did not report others being concerned about their drinking or had not been given advice to cut down. Conclusion: It is feasible to use the AUDIT screening tool in the ED to identify those at risk from hazardous drinking. In our ED there is a high prevalence of hazardous alcohol consumption in young adult patients, many of whom have not previously received advice to cut down on their drinking.     

Cannabinoid Hyperemesis Syndrome: Pathophysiology and Treatment in the Emergency Department

Background

Cannabinoid hyperemesis syndrome (CHS) is a challenging clinical disorder. CHS patients frequently present to the emergency department and may require treatment for intractable emesis, dehydration, and electrolyte abnormalities. Thought to be a variant of cyclic vomiting syndrome, CHS has become more prevalent with increasing cannabis potency and use, as enabled by various states having legalized the recreational use of cannabis.

Cannabinoid Hyperemesis Syndrome: An Update for Primary Care Providers

Cannabis is the most commonly used recreational drug worldwide. Crossbreeding and genetic modification techniques have dramatically increased the delta-9-tetrahydrocannabinol content, with resultant increased rates of cannabis use disorders and other toxic effects among users. Cannabinoid hyperemesis syndrome (CHS) is a recently identified disorder and should be considered as a differential diagnosis in patients exhibiting recurrent symptoms of abdominal pain, weight loss, intractable vomiting, and compulsive bathing. Treatment includes vigorous rehydration with intravenous fluids, antiemetics, proton pump inhibitor administration, weight monitoring, and cannabis use cessation. Awareness of CHS symptomology and clinical management strategies can prevent extensive diagnostic workups and unnecessary hospitalizations.     

The role of carbamazepine and oxcarbazepine in alcohol withdrawal syndrome

Objective: The goal of this review is to evaluate the efficacy and safety of carbamazepine and oxcarbazepine in treatment of alcohol withdrawal syndrome (AWS) and determine the role in therapy of both agents. Methods: Relevant literature was identified through a search of MEDLINE (1966–June 2008), PubMed (1966–June 2008); Cochrane database was performed to identify English‐language publications. Search terms included carbamazepine, oxcarbazepine, AWS, alcoholism, substance syndrome withdrawal. Results: In seven studies, including 612 patients, carbamazepine demonstrated significant reduction in alcohol withdrawal scores. However, in comparative trials with a benzodiazepine agent, carbamazepine’s ability to prevent alcohol withdrawal seizures (OR = 0·93; 95% CI = 0·06–14·97, P = NS) and delirium tremens (DTs; OR = 1·25; 95% CI = 0·28–5·64, P = NS) was uncertain as a result of insufficient patient enrolment. In three trials, carbamazepine failed to reduce alcohol withdrawal symptoms possibly as a result of delayed administration, inadequate dosage or inadequate sample size. At daily doses of 800 mg either fixed or tapered over 5–9 days, carbamazepine was well tolerated, and safely administered when blood alcohol concentration dropped below 0·15%. The role of oxcarbazepine in AWS is undefined because of inconsistent findings in two trials. Conclusion: Carbamazepine has demonstrated safety, tolerability and efficacy in treatment of moderate to severe symptoms of alcohol withdrawal in the inpatient setting. However, trials of carbamazepine provide inconclusive evidence for prevention of alcohol withdrawal seizures and DTs in comparison with benzodiazepines. Benzodiazepines remain the primary treatment of moderate to severe AWS.     

Cannabinoid Hyperemesis: A Case Series

Background: Cannabinoid use is prevalent in the United States, with recent reports of increased usage among younger Americans. Traditionally, cannabinoids have been used recreationally or as antiemetics; however, recent reports suggest that chronic abuse can result in the paradoxical effect of a cyclic vomiting syndrome, termed cannabinoid hyperemesis. Objective: We report on this recently described clinical syndrome characterized by severe nausea and hyperemesis in the setting of chronic cannabinoid use. Case Reports: We report the cases of 3 patients who presented to two academic emergency departments (EDs) on multiple occasions with nausea and vomiting in the setting of chronic cannabinoid use. There were extensive medical evaluations and frequent inpatient hospital admissions before the diagnosis of cannabinoid hyperemesis was considered. Conclusion: With the relatively high prevalence of cannabinoid use in the United States and increasing interest in the applications of marijuana for therapeutic purposes, this entity may be encountered in the ED. Cannabinoid hyperemesis should be considered in the differential diagnosis of patients presenting with similar symptoms.     

A Systematic Review on Cannabis Hyperemesis Syndrome and Its Management Options

IntroductionSeveral forms of cannabinoids are currently being used to manage nausea and vomiting (N/V). Emerging cases of refractory N/V associated with chronic cannabis use among adults and older patients have been reported named cannabis hyperemesis syndrome (CHS). CHS is a condition that leads to repeated and severe N/V in long-term users of cannabinoids.ObjectiveThe aim of this study was to outline current treatments for the management of CHS.MethodsA systematic review was conducted using PubMed, Ovid MEDLINE, Cochrane Central, EMBASE, and Google Scholar. Databases were used to search for articles on CHS published from January 2009 to June 2021, yielding 225 results of which 17 were deemed relevant and underwent review by 2 separate reviewers.ResultsThe duration of cannabis administration ranged between 6 months to 11 years may precipitate symptoms of CHS. The Rome IV diagnostic criteria of CHS require cannabinoid use and persistence of N/V symptoms for at least the past 6 months. Cannabis cessation is noted to be the most successful management, but other treatments also demonstrated symptom relief; these include hot water hydrotherapy, topical capsaicin cream, haloperidol, droperidol, benzodiazepines, propranolol, and aprepitant administration.ConclusionMore research on CHS is needed to enhance knowledge translation, education, and create awareness in the medical community on the side effects of cannabinoids and to propose the best treatment options.     

Effect of early and focused benzodiazepine therapy on length of stay in severe alcohol withdrawal syndrome

Objective: Current evidence supports symptom-triggered therapy for alcohol withdrawal syndrome (AWS). Early, escalating therapy with benzodiazepines (BZD) appears to decrease ICU length of stay (LOS); however, the effect on hospital LOS remains unknown. The hypothesis of this study is that focused BZD treatment in the first 24?h will decrease hospital LOS.

Design: Pre–post cohort study.

Setting: Academic medical center.

Patients: This study included patients with severe AWS. The pre-intervention cohort (PRE) was admitted between January and November 2015. The post-intervention cohort (POST) was admitted between April 2016 and March 2017. Severe AWS was defined as patients requiring diazepam doses of >30?mg. Focused treatment was defined as >50% of total diazepam usage within the first 24?h of recognition of AWS.

Intervention: In the PRE group, patients received symptom-triggered, escalating doses of diazepam and phenobarbital based on their Richmond Agitation-Sedation Scale (RASS). In the POST group, patients received a revised, time-limited course of therapy: escalating doses of BZD and phenobarbital were given during a 24-h loading phase, and all therapy was discontinued after a 72-h tapering phase. The SHOT scale was used as an adjunct to RASS to assess non-agitation symptoms of AWS and guide additional diazepam doses.

Measurements and main results: The primary outcome was hospital LOS; secondary outcomes included ICU LOS, BZD use, and ventilator-free days. Five hundred thirty-two patients were treated using the AWS protocol; 113 experienced severe AWS. The PRE (n?=?75) and POST (n?=?38) groups were evenly matched in age, sex, history of AWS, and severity of illness. There was a substantial difference in POST patients who received focused treatment (51.3% vs. 73.7%, p?=?.03). The POST group had a significant decrease in hospital LOS (14.0 vs. 9.8 days, p?=?.03) and ICU LOS (7.4 vs. 4.4 days, p?=?.03).

Conclusion: Early, focused management of severe AWS was associated with a decrease in ICU and hospital LOS.     

Patients with Alcohol Problems in the Emergency Department,Part 1: Improving Detection*

Abstract. Medical and social problems related to alcohol use are frequently seen in the ED. Often, the tempo of emergency medicine practice seems to preclude assessment beyond that required by the acute complaint. However, detection of ED patients with alcohol problems can occur using brief screening tools. This article was developed by members of the SAEM Substance Abuse Task Force, and describes screening tools that have been used successfully to identify atrisk and dependent drinkers. Their brevity, reproducibility, and accuracy vary somewhat, but screening can be realistically performed in the busy ED setting. The early detection of patients with alcohol problems would provide the opportunity for early intervention, and may reduce subsequent morbidity and mortality in this patient population.     

Efficacy of topical capsaicin for cannabinoid hyperemesis syndrome in a pediatric and adult emergency department

IntroductionCannabinoid hyperemesis syndrome (CHS) is a clinical diagnosis characterized by symptoms of recurrent nausea, vomiting, and severe abdominal pain in the setting of chronic cannabis use. Symptoms of CHS are frequently unresponsive to standard antiemetic therapy. Topical capsaicin applied to the abdomen has been cited as a potential effective agent for CHS however robust evidence is lacking.MethodsThis was a single-center retrospective cohort study to evaluate the efficacy of topical capsaicin in pediatric and adult patients presenting to the emergency department (ED) with suspected or confirmed CHS. The primary outcome assessed was if utilization of capsaicin for CHS resulted in more patients achieving an “efficacious” result, defined as only requiring ≤1 rescue medication for symptom relief after receiving capsaicin or after administration of the first agent in patients who did not receive capsaicin during their ED course. Secondary outcomes included total ED length of stay, time to discharge after administration of the reference agent (RA), proportion of patients requiring admission, total number of medication doses given for symptom relief, change in pain score and episodes of emesis, and proportion of patients returning to the ED within 24 h for the same complaint. Additional analyses were also performed to explore patient characteristics that may be predictive of capsaicin efficacy.Results201 patients were included in the final analysis of which 25 were <21 years old and seen in the pediatric ED. A greater proportion of patients in the capsaicin group achieved the primary outcome of efficacy as compared to patients who did not receive capsaicin (55% vs 21%, p < 0.001, unadjusted OR 1.44 [95% CI 0.586–0.820]). There were no differences in secondary outcomes except for time to discharge after administration of the RA which was shorter in the capsaicin group (3.72 vs 6.11 h, p = 0.001).ConclusionSignificantly more patients in the capsaicin group experienced efficacy compared to patients who did not. Time to discharge after administration of the reference agent was shorter for those who received capsaicin compared to patients who did not. Administration of capsaicin did not influence patients' total number of medications received or total ED length of stay. Future research is needed to determine capsaicin's efficacy when utilized earlier in therapy, ideally upon initial diagnosis of CHS, and before additional adjunct medications are administered.     

Should age be incorporated into the adult triage algorithm in the emergency department?

ObjectiveTo compare resource utilization and mortality between older and younger adult patients with similar ED chief complaints and ESI triage levels.MethodsThis was an observational study of consecutive adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with chest pain, abdominal pain, altered mental status, generalized weakness, or headache. Patients were categorized into 40–64, 65–79, and ≥ 80-year old groups. Mortality and utilization outcomes were compared between age groups through logistic regression models or Cox proportional hazards adjusting for ESI level and chief complaint. Odds ratios (OR) and hazard ratios (HR) were calculated with 95% confidence intervals (CI).ResultsA total of 9798 ED visits were included. As compared to younger adults (age 40–64), older adults, independently of ESI level and chief complaint, had higher ED laboratory use (OR 1.46 [CI 1.29, 1.66] for age 65–80; OR 1.33 [CI 1.15, 1.55] for age ≥ 80), ED radiology use (OR 1.40 [CI 1.26, 1.56]; OR 1.48 [CI 1.30, 1.69]), hospital admission (OR 1.56 [CI 1.42, 1.72]; OR 1.97 [CI 1.75, 2.21]), and ICU admission (OR 1.38 [CI 1.15, 1.65]; OR 1.23 [CI 0.99, 1.52]). Despite similar ESI and chief complaint, patients age 65–79 and ≥ 80 had higher 30-day mortality rates (HR 1.87 [CI 1.39 to 2.51] and 2.47 [CI 1.81 to 3.37], respectively).ConclusionsOlder adults with similar chief complaints and ESI levels than younger adults, have significantly higher ED resource use, hospitalization rates, and mortality.     

Increased Detection of Alcohol Consumption and At-risk Drinking with Computerized Alcohol Screening

Background

The impact of alcohol use has been widely studied and is considered a public health issue. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends Screening and Brief Intervention and Referral Treatment (SBIRT), but the actual practice in the Emergency Department (ED) is constrained due to limited provider time and financial resources.

Objectives

To assess the effectiveness of alcohol screening using Computerized Alcohol Screening and brief Intervention (CASI) compared to alcohol screening by triage nurse during Medical Screening Examination (MSE) in the ED.

Methods

Retrospective review of CASI/MSE database from January 2008 through December 2009, collected in the tertiary, Level I Trauma ED was performed. Inclusion criteria included age ≥18 years, and completion of both the MSE and CASI. We analyzed the database by comparing age, gender, primary language (English, Spanish), and Alcohol Use Disorders Identification Test scores using McNemar's test.

Results

Data were available for 5835 patients. CASI showed a significant increase in detection of at-risk drinking over MSE across all ages, gender, and primary language (p < 0.05). MSE found 2.5% at-risk drinkers and CASI found 11.5% at-risk drinkers (odds ratio [OR] 8.88, 95% confidence interval [CI] 6.89–11.61). Similar results were found in 18- to 20-year-old patients. MSE identified 1.8% at-risk drinkers and CASI reported 15.94% (OR 19.33, 95% CI 6.30–96.47).

Conclusion

CASI increased detection of at-risk alcohol drinkers compared with MSE across all ages, gender, and primary language. CASI is a promising innovative method for alcohol screening in the ED for the adult population, including under-aged drinkers.     

Goal-directed abdominal ultrasonography: impact on real-time decision making in the emergency department

The impact of “goal-directed” abdominal ultrasound (US) on real-time decision making in the Emergency Department (ED) was studied, with specific emphasis on the certainty of diagnosis, treatment, and disposition plans. A prospective, interventional study enrolled 212 patients at a county teaching hospital ED, who underwent bedside US by experienced ED sonographers. A study questionnaire was completed documenting the US indication, working diagnosis, treatment, and disposition plan. The physicians assigned pre-test and post-test levels of certainty for the diagnosis, treatment plan, and disposition on an integral scale from 1 to 10. Scores for diagnosis were further categorized into low (1–3), moderate (4–7) and high certainty of disease. Absolute mean changes in level of certainty for diagnosis, treatment, and disposition were 3.2 (95% CI 3.1–3.3), 2.0 (95% CI 1.9–2.1), and 1.9 (95% CI 1.8–2.0), respectively. The direction of change after US for certainty of diagnosis was evenly split, with 47% increasing and 47% decreasing. The majority of patients categorized as either high or low certainty of disease had US results concordant with the physician’s initial assessment. However, 16% moved from either high to low or from low to high certainty categories after US. Patients with moderate certainty moved evenly to either the low or high post-test category in 97% of cases. Treatment and disposition decisions were less impacted by US, with the majority of cases increasing in certainty irrespective of the US results. Bedside ultrasonography in the ED has an important impact on real-time decision-making, particularly in terms of the certainty of diagnosis.