In women, a pregnancy test is necessary to assess for any pregnancies, especially ectopic pregnancies. Imaging is up to the discretion of the clinician, depending on various specific factors of history or physical exam, which may be concerning for surgical processes. The SAEM GRACE program addresses the best practices for the care of the most common chief complaints that can be seen on the tracking board of any emergency department in the country, based upon research and expert consensus. These guidelines are designed with de-implementation as a guiding principle to reasonably reduce wasteful testing, provide explicit criteria to reduce foreseeable risk, and define sensible and prudent medical care. CHS and CWS are rapidly becoming major public health issues and add to the caseloads of already chronically overburdened ED. Optimization of ED care is possible but requires understanding the pathophysiological differences of each syndrome.
About this article
As CHS is a relatively recently recognized and studied phenomenon easily confused with other diseases, there is a paucity of sizeable randomized control studies. Most resources and recommendations come from case studies and expert opinions. In addition to appropriate antiemetic therapy, fluid resuscitation, and management of the patient’s symptoms, patients must recognize behaviors and exposures that place them at risk for their pathology.
Efficacy of topical capsaicin for cannabinoid hyperemesis syndrome in a pediatric and adult emergency department
Interaction of CB receptors with the TRPV1 receptor explains further this phenomenon and the therapeutic effect of capsaicin cream (see below), with high doses of cannabinoids causing hypothermia and low doses of hyperthermia [9]. Although often presenting with similar symptoms such as abdominal pain and vomiting, cannabinoid hyperemesis syndrome (CHS) and cannabis withdrawal syndrome (CWS) are the result of two differing pathophysiological processes. Distinguishing between these two syndromes is essential to provide appropriate symptomatic options.
PROCESS TO DEVELOP CHS TREATMENT GUIDELINE
- While no consensus exists pertaining to the minimal duration of exposure, one study demonstrated that smoking ≥ 6 marijuana joints/day over 12 months triples the odds of CWS (in comparison to smoking 1 joint/day over the same period) [13, 21].
- Interaction of CB receptors with the TRPV1 receptor explains further this phenomenon and the therapeutic effect of capsaicin cream (see below), with high doses of cannabinoids causing hypothermia and low doses of hyperthermia [9].
- If you have cannabis use disorder and need help quitting, professional treatment is available.
- Symptoms of CHS typically come on several years after the start of chronic marijuana use.
Hot showers and baths were cited in all level-4 and -5 articles as universally effective. Benzodiazepines, followed by haloperidol and capsaicin, were most frequently reported as effective for acute treatment, and TCAs for long-term treatment. As the prevalence of CHS increases, future prospective trials are greatly needed to evaluate and further define optimal pharmacologic treatment of patients with CHS. For CHS, cardinal symptoms are cyclic vomiting accompanied by abdominal pain following cannabis consumption. These symptoms can be alleviated by hot showers, and complete resolution of the syndrome requires complete abstinence [15].
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- Opioids, while often prescribed for the patient’s debilitating abdominal pain, are not appropriate for CHS, as they may, in fact, worsen nausea and vomiting.
- It tends to affect people who use cannabis at least once a week and happens more often in adults who’ve been using cannabis since their adolescent years.
- The GRACE-4 multidisciplinary panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRACE) approach to assess the certainty of evidence and strength of recommendations regarding three questions for adult ED patients coming to the ED with AWS, AUD, or CHS.
- A recent study found that human papillomavirus vaccination when aged under 20 years, coupled with active surveillance for cervical intraepithelial neoplasia grade 2, significantly lowers the risk of cervical intraepithelial neoplasia grade 3 or cervical cancer.
Adolescents with CHS and cannabis use disorder (CUD) benefit from a combination of pharmacologic treatment, behavioral interventions, and family support. It’s a condition that can lead to serious health complications if you don’t get treatment for it. MR and EPH conceptualized the article, reviewed the literature, and drafted the first version. All authors read, corrected, developed figures/tables, and approved the final manuscript. All data generated or analyzed during this study are included in this published article.
Treatment / Management
- It is of interest to note that abdominal pain and vomiting are not included in the diagnostic criteria for the DSM-5; this further reflects the importance of a thorough medical history in establishing a diagnosis.
- This activity introduces the pathophysiology, clinical manifestation, and management of cannabis hyperemesis.
- No correlation has been established between symptoms severity and quantity (of THC) previously consumed, and initial presentation (to acute care) tends to vary, with a clinical course not well defined.
Worse, frequent ED consultations have been shown to lead to cognitive bias from teams, which could trivialize symptoms and result in missed alternative diagnoses [45]. In light of these factors, and based on the above literature review, we proceeded to review the management of chronic cannabis users presenting cannabinoid hyperemesis syndrome to our ED with hyperemesis, nausea, and/or abdominal pain. In a bid to share with other acute care units, we will now present our internal guidelines, reflecting the current level of evidence. The incidence of cannabinoid hyperemesis syndrome in patients presenting to U.S. emergency departments is increasing.
- °C, degrees Celsius; CHS, cannabinoid hyperemesis syndrome; ED, emergency department; GI, gastrointestinal; IM, intramuscular; IV, intravenous; ODT, orally disintegrating tablet; OTC, over the counter; PO, orally; TID, three times a day; TRPV1, transient receptor potential (vanilloid) cation channel 1; UDS, urine drug screen.
- Cannabinoid hyperemesis syndrome (CHS) is a condition in which a patient experiences cyclical nausea, vomiting, and abdominal pain after using cannabis.
- Capsaicin is a readily available topical preparation that is reasonable to use as first-line treatment.
- Drugs with an anticholinergic effect may likewise block medullary mediated vomiting, though they may have minimal impact on visceral stimulation, including the crippling abdominal cramping pain that patients with CHS experience.
