Cannabinoid Hyperemesis Syndrome – PediaCast CME 095
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Show Notes
Description
- Alicia McVity, Dr Leah Middelberg, and Dr Alek Adkins visit the studio as we consider cannabinoid hyperemesis syndrome. The legalization of recreational marijuana has led to a drastic rise in this condition, which results in nausea, vomiting, and dehydration. Tune in as we explore the details!
Instructions to obtain CME/CE Credit
- Read this information page.
- Listen to the podcast.
- Complete the post-test at Nationwide Children’s CloudCME.
- You can view your transcript and print a certificate of completion at Cloud CME.
- Need help creating a Cloud CME account? Click Here.
- Still have questions? Contact CMEOffice@nationwidechildrens.org
Topics
- Cannabinoid Hyperemesis Syndrome
Presenters
Learning Objectives
At the end of this activity, participants should be able to:
- Define Cannabinoid Hyperemesis Syndrome (CHS) and describe its risk factors, signs, and symptoms.
- Develop a differential diagnosis and work-up plan for the pediatric patient presenting with symptoms typical of CHS.
- Manage the patient with CHS presenting to the outpatient or inpatient setting.
- Provide education to the patient to prevent future episodes of CHS.
Links
- Emergency Medicine at Nationwide Children’s Hospital
- Toxicology at Nationwide Children’s Hospital
- Cannabinoid Hyperemesis Syndrome (UpToDate)
Disclosure Statement
- No one in a position to control content has any relationships with commercial interests.
Commercial Support
- Nationwide Children’s has not received any commercial support for this activity.
CME/CE Information
- In support of improving patient care, Nationwide Children’s Hospital is jointly accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for the healthcare team. (1.0 ANCC contact hours; 1.0 ACPE hours; 1.0 CME hours)
- Nationwide Children's Hospital has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credits. Approval is valid for 2 years from the date of the activity. PAs should only claim credit commensurate with the extent of their participation.
- As a Jointly Accredited Organization, Nationwide Children's Hospital is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Nationwide Children's Hospital maintains responsibility for this course. Social workers completing this course receive 1.0 continuing education credits.
- Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs.
Contact Us
- CMEOffice@nationwidechildrens.org
Episode Transcript
Announcer: This is Pediacast CME. Welcome to Pediacast CME, a pediatric podcast for providers. And now direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr Mike Patrick: Hello everyone. And welcome Once again to Pediacast CME. It is a continuing medical education podcast for healthcare providers. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital.
Dr Mike Patrick: We're in Columbus, Ohio. It's episode 95. We're calling this cannabinoid hyperemesis syndrome. I want to welcome all of you to the program. So this week we have a guest host, Alicia McVeighty.
Dr Mike Patrick: She is a nurse practitioner in Emergency Medicine at Nationwide Children's Hospital, and she's also a member of the Pediacast CME Planning Committee. Now, as you've heard me say many times over the course of the last couple of years, we are accredited for Category 1 continuing medical education activities, not only for physicians, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And we do, because we wanted great representation on our topics for all of these groups, The Pediacast CME Planning Committee sort of kicked off with a new group of folks this year. And we have someone representing all of those different disciplines. And each committee member came up with a topic, really did a lot of the planning for this coming year in terms of scheduling the guests, writing the interview questions, the learning objectives, putting the post-test together, all of those things.
Dr Mike Patrick: And so this really is Alicia's baby. And so we're really excited. She did a fantastic job too, by the way. We're just really excited to move on and go forward with some guest hosting activities over the course of the next year. So really special thanks to Alicia, again, nurse practitioner in emergency medicine at Nationwide Children's Hospital.
Dr Mike Patrick: We're going to meet her shortly. Our topic today is a pretty interesting 1, cannabinoid hyperemesis syndrome and marijuana was recently approved for recreational use in Ohio and of course already approved for recreational use in many states. And What that means is that there is more cannabis inside our homes and folks are using it more and more and the cannabis that's out there today compared to the products that were out there previously, like as we think about the 1960s, for example, is much more potent. And so there are several conditions and complications that can come with chronic use of more potent cannabinoids or cannabis products. And 1 of those conditions is known as cannabinoid hyperemesis syndrome.
Dr Mike Patrick: It's something you are going to see if you take care of teenagers. And trust me, we are seeing a lot of it in our emergency department, which is why Alicia chose it as an important topic for us to consider. Our guests today, our great ones, Dr. Liam Middleburg is with emergency medicine at Nationwide Children's and Dr. Alec Adkins is a toxicologist Here at our hospital before we get to them and the topic and dive deep into all of it I do want to remind you you can find PDA cast CME really wherever podcasts are found So in the Apple and Google podcast apps, I heart radio, Spotify, SoundCloud, Amazon music, YouTube, and most other podcast apps for iOS and Android.
Dr Mike Patrick: Please consider subscribing if you like the show that way you won't miss an episode and also please consider leaving a review wherever you listen to podcasts so that others who come along looking for free continuing medical education credit will know what to expect. Speaking of that educational credit, it is easy to claim your Category 1 CME. Simply listen to the podcast, which you are about to do, and then head over to the show notes for this episode at pediacastcme.org. It's episode 95, and you'll find a link to the post-test there in the show notes. Follow that link to Cloud CME, take and pass the post-test, and the Category 1 credit is yours.
Dr Mike Patrick: You'd have to click on the materials link. That's where you'll find the actual post-test over at Cloud CME. But again, just start with the link in the show notes and it'll take you there. Of course, you wanna be sure the content of this episode matches your scope of practice, but given how much marijuana is out there and how much we are seeing of this particular condition. Really I think it does pertain to just about everyone who takes care of teenagers.
Dr Mike Patrick: Also don't forget to connect with us on social media. We are on Facebook, Instagram threads, LinkedIn, and Twitter. Simply search for PDA Cast. And we also have that handy contact link over at pediacastcme.org. If you would like to suggest a future topic for the program.
Dr Mike Patrick: Also want to remind you the information presented in every episode of our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. Our discussion may contain only a portion of relevant information and should not be solely relied upon for the diagnosis or treatment of any medical condition. We do not cover every possible treatment option and the treatment options we do cover do not include every possible use, precaution, side effect, or interaction. Also, your use of this audio program is subject to the Pediacast CME terms of use agreement, which you can find at pediacastcme.org.
Dr Mike Patrick: So let's take a quick break. We'll get our expert panel settled into the studio, and then we will be back to talk about cannabinoid hyperemesis syndrome. It's coming up right after this. Dr. Leah Middelburg is an emergency medicine physician at Nationwide Children's Hospital and an assistant professor of pediatrics at the Ohio State University College of Medicine.
Dr Mike Patrick: Dr. Alec Adkins is a toxicologist at Nationwide Children's and an assistant professor of pediatrics and emergency medicine at Ohio State. They both have a passion for treating and preventing cannabinoid hyperemesis syndrome, which is our topic today. So let's give a warm PDA cast welcome to Dr. Leah Middleburg and Dr.
Dr Mike Patrick: Alec Adkins. Thank you both for being here today.
Dr Leah Middelberg: Thank you for having me.
Dr Alek Adkins: Yes. Thank you for having me today.
Dr Mike Patrick: Yeah, we are really glad that you guys were able to make time in your schedule for us. We appreciate it. Also wanna thank Alicia McViedy and welcome her to the program. She's gonna be our guest host this week to guide us through the conversation. She's a nurse practitioner with emergency medicine at Nationwide Children's and a member of the Pediacast CME Planning Committee.
Dr Mike Patrick: So Alicia, thank you for all of your hard work putting this episode together. We really appreciate you being involved with the program as well.
Alicia McVity: Thank you for having me.
Dr Mike Patrick: Yes, we are excited. And So without further ado, I am going to turn the reins over to Alicia. And if you want to go ahead and get us started as we think about cannabinoid hyperemesis syndrome.
Alicia McVity: Hi. Yeah, thanks. Dr. Middleberg, what is cannabinoid hyperemesis syndrome? And we're going to shorten that today to CHS.
Dr Leah Middelberg: Hey, Alisha. Thank you. Yeah, and I love the idea of shortening to CHS, because obviously a little bit of a mouthful. You know, cannabinoid hyperemesis syndrome first was really described kind of early 2000s. And it's essentially a syndrome of cyclic vomiting and nausea.
Dr Leah Middelberg: So cyclic meaning we have these cycles where these symptoms seem to repeat over and over and this type of ND is related to chronic cannabis use. So this is often really sounds confusing to people because a lot of folks think that cannabis is an anti-nausea or anti-vomiting agent, right? I think a lot of times people think about it as something maybe people use as an adjunct for those undergoing chemotherapy who have nausea that maybe isn't controlled by other medicines. But the cannabis products are becoming more potent and so it may explain why we're starting to see actual ill effects and some of this paradoxical reaction, meaning it's basically the opposite effect of what you would think, much like when someone gets really energetic after taking a medicine that's supposed to make them drowsy. So, you know, instead of seeing those anti-nausea and anti-vomiting properties, we're really seeing these cycles of nausea and vomiting after chronic cannabis use.
Alicia McVity: Thank you. Dr. Adkins, can you tell us what causes CHS?
Dr Alek Adkins: Yeah, so it's a little slip in the air as to the exact mechanism of what causes it, but what we believe is happening is a dysregulation of some receptors in the brain and the gut. So there are these cannabinoid receptors in everyone's brain called CB1 and CB2. They're found in the brain, they're found in the gut, they're found in the muscles. We see them on even our immune cells, our white blood cells too. And we know, from what we do know, is that they play an important role in helping with nausea control, regulating our body temperature, regulating sort of inflammatory responses throughout the body.
Dr Alek Adkins: So they have a really key integral role and they play their role with another protein called Transate Receptor Protein, or TRP. And then in this case, it's TRPv1, kind of a mouthful. But that is really the cannabinoid receptors in this TRPV1 play an integral role in balancing out different parts of our nervous system. So, the global agreed-upon theory is that there is some sort of tipping scale, and this balance between these 2 receptors gets out of whack with cannabis use, and that's what causes the vomiting. Some processes are thinking about that.
Dr Alek Adkins: You basically need to prime the system. And so THC or tetrahydrocannabinol is the main cannabinoid that we talk about when we're talking about marijuana and marijuana products. But there's hundreds of different cannabinoids available. Cannabidiol or CBD is another 1. And these love to live in the fats in our brain and our body.
Dr Alek Adkins: And there are some thoughts that you need to be exposed to these over time for long periods of time for it to build up in the brain. And then during times of stress when your body wants to use its fat as energy, you get this big release of cannabinoids like THC and that's what tips you over. There's some thought process Dr. Middleburg kind of alluded to is that as this is not your grandmother's marijuana anymore and the strains these days are a lot more potent And so there's some thought that just the sheer amount of cannabinoids that's found in these newer products is enough to overstimulate your endogenous or your native cannabinoid system and cause everything out of balance. And so that we've seen in animal models and other human models that it can cause things like your body to feel cold when it's not.
Dr Alek Adkins: It can cause the balance between nausea and vomiting to go out of whack and then you have a bunch of episodes of nausea and vomiting. These receptors also play a role in pain in the gut system, which is why a lot of our patients will experience pain and abdominal cramping and pain with it. There's also some thought that genetics are playing a role into this too. There's different enzymes in your body that help break down these cannabinoids. And some people are slow metabolizers.
Dr Alek Adkins: And as we're getting more and more cannabinoids in our marijuana products, our cannabis products, there's some thought process that people cannot keep up with the metabolism and it is causing them to be more susceptible to these bouts of cannabis hyperemesis.
Alicia McVity: Thanks. Dr. Middleburg, what are some of the most common symptoms that you see with CHS?
Dr Leah Middelberg: Yeah, so symptoms usually start within 24 hours of the last time someone used a cannabis product. And symptoms often are described as kind of going through 3 stages. The first stage is this prodromal or kind of like pre-stage, right? And this is where people might suffer from kind of mild nausea, a little bit of abdominal discomfort. Usually the symptoms are worse in the morning, but people actually sometimes increase their cannabis use trying to self-treat during these times.
Dr Leah Middelberg: And so the classic thing we often hear from folks in this kind of early stage and then throughout later stages is actually people start taking hot showers or baths and they're taking them pretty frequently because they do notice that is a little bit of a learned behavior that decreases their symptoms. And this is a really specific kind of entity to this problem. So it was really helpful later down the road when we're kind of talking about making a diagnosis. But the initial phase of these kind of mild, you know, annoying symptoms can last for months really before, and some people may never kind of progress into the more active phase, but it can last for a significant period of time before we kind of get to that hyper-rheumatic or like significant vomiting phase. Usually this initial phase, folks are still able to eat okay.
Dr Leah Middelberg: They're not really having a lot of weight loss And they can you know kind of kind of keep up some normal behavior, but they're just in general not feeling well Then it usually progresses to that active hyper emetic or lots of vomiting phase. This is when we see people presented to the hospital most likely. This is the phase where that nausea significantly worsens, people are having frequent episodes of vomiting or retching, And that frequency is described as as frequent as 4 to 5 times an hour, 12 to 15 cycles a day. So you can kind of get a sense that it's happening really pretty constantly. And then people are also noticing that abdominal pain that Dr.
Dr Leah Middelberg: Atkins mentioned. Usually they're describing the pain kind of right in the middle of their belly or really kind of up top at the at the top of their stomach at the bottom of their ribcage and it kind of comes in these cycles much like the vomiting. This active really unpleasant part usually lasts for a couple days, as long as cannabis use has been stopped. But it can last up to a week or 2 even. And this is when we see people come to the hospital with things like dehydration, kidney injury because their electrolytes and their hydration can get so out of whack, weight loss.
Dr Leah Middelberg: They can actually get irritation to the esophagus, which is that tube that helps carry food from your mouth down to your stomach. Because as you imagine, all that vomit is coming up. It's really irritating to your body. And we can, you know, even actually see sometimes burn burn type symptoms from people taking those really frequent hot showers trying to make themselves feel better. If the cannabis is stopped and folks are able to get over this acute, kind of really unpleasant phase, then we go into the third and final phase, which is recovery.
Dr Leah Middelberg: And this is usually kind of a slow return to their normal nutritional intake. They start kind of regaining a little bit of that weight that they've lost. And this can, you know, happen within a couple days, but it could take weeks to months for people to really feel completely normal and to kind of get back to where they were.
Dr Mike Patrick: If I could butt in just very quickly, I think it's so interesting that it can be up to 24 hours after the last use of cannabis before you see these symptoms. So it's not like when you have that euphoric sort of intoxicated effect. It's like a lot longer. Alec, why is there that delay?
Dr Alek Adkins: I think it kind of goes back to what I was talking about earlier, where these cannabinoids are very fat-soluble, and they live in the fat. And 1 of the theories behind that is in episodes of stress either you've been fasting, haven't been eating well, you're emotionally or physically stressed, your body will switch from wanting to use sugars for energy to fats and in that process you can get a release of the THC and other cannabinoids and I think it's that release that triggers your cannabinoid receptors being not well balanced out in the brain anymore and that's what could trigger these episodes. So I am not surprised that it can be several hours even a day after your last cannabis use to fill symptoms.
Dr Mike Patrick: Yeah, very interesting.
Alicia McVity: Yeah, so Dr. Middleberg, with all of those symptoms that we see with CHS, when someone's presenting that doesn't have a history of this, I'm sure that the differential that you would have to go through to kind of come to that diagnosis is pretty vast.
Dr Leah Middelberg: Yeah, you're exactly right. In the emergency department, which is where I work, vomiting is a pretty common symptom and can mean a lot of different things. The entity that kind of most closely overlaps, and there's still I think a little bit of gray zone into who has maybe white with the CHS is actually something called cyclic vomiting syndrome. So you can tell even the name is really kind of closely related. This is an entity that also has recurrent episodes of vomiting.
Dr Leah Middelberg: And like CHS, the episodes have that frequent kind of constant vomiting that kind of runs in these cycles. But these episodes are usually separated by weeks and months where people are pretty much back to their baseline in between. And some of the main differences between CHS and cyclic vomiting is really in the history, which is, and we're going to talk about it a little bit more, but you know, the history and the physical is where you're going to be able to best kind of point your arrow towards what's going on here. With cyclic vomiting, we tend to maybe have a family history of things like migraines. Folks will not do that classic, I'm taking hot showers because it makes me feel better kind of part of the history.
Dr Leah Middelberg: And cyclic vomiting usually starts pretty suddenly versus that long prodrome we talked about of that like I'm kind of slowly feeling worse and worse over a period of time that happens with CHS. Unfortunately, some people with cyclic vomiting will self-treat again with cannabis products And that can really muddy the water because then you're trying to decide, gosh, is this cannabis related or is this unrelated? And really the best way to differentiate is to have a period of abstaining or kind of not using cannabis products so we can really see, hey, are symptoms stopping or are they continuing? But that's kind of a little bit of also rare entity that most closely overlaps with CHS, but the normal everyday run-of-the-mill stuff we see with vomiting is pretty vast as well. Age is actually a really big helpful factor here because the age of your patient is going to kind of really put you on a different thought process.
Dr Leah Middelberg: For instance, someone who's 60 is going to have different problems than the 16-year-old that comes to see me. So, you know, in teens and young adults, we don't really see things like diverticulitis or those chronic blood flow issues to the bowels, but we do see the run-of-the-mill stomach bugs that kids pick up at school from friends. You know, we frequently see things like appendicitis, you know, potentially ovarian pathology in our female patients or even pregnancy. So, you know, helping kind of differentiate who's at risk for what is really helpful. And then some other things we always kind of think about, you know, would be food sensitivities, gastric reflux, liver or pancreas issues, bowel obstructions, urinary problems, or even brain issues.
Dr Leah Middelberg: And those are all just kind of things you think about when you see vomiting. And like I said, that history and physical is really gonna be key in helping you narrow down that list.
Alicia McVity: Yeah, absolutely. I can see where just getting the time to take those, to ask those extra questions, especially about shower use, can make a big difference with these kids and how you go forward treating them. So Dr. Atkins, tell me what are some risk factors for CHS?
Dr Alek Adkins: So, kind of touching it briefly, so there are some genetic risk factors. So, patients who do not have the TRPV1 receptor or express low levels of that receptor at baseline. They're at higher risk because any sort of cannabis use is going to throw that delicate balance off and kind of tip them over into cannabis hyperemesis. Patients who are also have genetic predispositions to not metabolize the THC, effectively also are at higher risk. And then really some other risk factors we kind of look for or when we're determining who is going to be at risk for high-over-cannabis hyperemesis is going to be a high daily use of cannabis.
Dr Alek Adkins: So we're talking 20 days a month or more is what a lot of these studies out there use to define as kind of chronic daily use. If you're More infrequent than that, it's less likely for you to develop it. And most of the patients and the studies that have been published so far, it's pretty consistent daily use and high doses and kind of ramping up of higher doses too. Other things that may kind of just put the patient at risk who's already primed to have cannabis hyperemesis syndrome. I talked about before is stress.
Dr Alek Adkins: So physiologic and emotional stress can lead to episodes of cannabis hyperemesis as well as poor nutrition and or maybe eating junk food or going out and partying or something else and just kind of tip them over from their nutrition status to a state of stress for the brain that can lead to the cannabis hyperemesis.
Alicia McVity: Thanks. So it sounds like between the history and the physical exam, are there other things that we can do to diagnose CHS, Dr. Middleburg?
Dr Leah Middelberg: So CHS is 1 of these diagnosis by exclusion diagnoses. So that means that unfortunately there's not a specific test to help us say, hey, this is definitely what you've got. But, you know, and especially in situations where it may be, like you mentioned earlier, the first time someone's presenting to the hospital for this issue, you know, a more extensive workup might be needed just to exclude those other dangerous things we talked about earlier. And again, the most important part is really that careful history and physical exam. You know, the history of a progression of nausea, maybe weight loss into like more acute vomiting, abdominal pain in conjunction with the chronic or frequent marijuana use, it can really kind of clue you in.
Dr Leah Middelberg: And then that extra bonus of, gosh, you know, what makes you feel better when you when you're feeling so bad like this? Taking hot showers, I'm doing this really frequently, and that does make me feel a little better for a little bit, can be a big flag to clue us in to what's going on. A couple things that help maybe differentiate CHS from maybe other stomach issues, you know, usually when you have that bad stomach bug with the vomiting that's pretty fast and furious. You also maybe have some changes in your bowel habits as well. Diarrhea, that kind of uncomfortable sensation.
Dr Leah Middelberg: And you don't really have that with CHS. Bowel habits tend to remain pretty normal and it tends to be that vomiting, nausea, abdominal pain that's the kind of main problem. There are some proposed diagnostic criteria or essentially, you know, components that when you're talking to someone and you get these pieces in your history can really kind of help encapsulate that diagnosis. Most of these diagnostic criteria really encompass components like description of the symptoms, severe cycles of nausea, vomiting, abdominal pain, maybe a correlation of symptoms with cannabis use, like symptoms stop when you're not using cannabis for several weeks, and that the person is at least a weekly marijuana user, or as Dr. Atkins mentioned earlier, more likely, more frequently.
Dr Leah Middelberg: And then the correlation of symptoms with maybe some of those learned, self-relieving things that folks may do. Other helpful clues, this so far has been an entity that we've mainly seen in younger adults, so less than 50 or so. That may be reflective more of cannabis use patterns, who is using cannabis to that amount of frequency, but may not be, the weight loss, the predominance of symptoms in the morning, and then really a normal workup, which you know, like I said, testing may be more significant in an initial visit, but as those tests are all coming back, the fact that many of them will be normal is pretty predictive of CHS.
Alicia McVity: What type of workup do you complete for these patients when they come in? What are some typical things that you do?
Dr Leah Middelberg: Yeah, so like I mentioned, the initial workup may look different than someone who has had an episode of CHS in the past and been diagnosed. So when you are initially coming in and you're not quite sure what the cause of these symptoms are, and you're maybe more suspicious for some of those other dangerous things. You may get more testing, so blood testing, looking at that liver functions, your kidney functions, your electrolytes, your infection fighting cells, urine testing, looking for infection, things like that. Imaging also may be performed at that time, x-rays, ultrasounds, or even CTs. And in CHS, the vast majority of these tests will be normal.
Dr Leah Middelberg: You know, you may see some abnormalities and things like electrolytes related to hydration and, you know, those derangements of the things that go wrong when you're losing a lot of fluids and not being able to keep anything in. As far as drug testing goes, most people are fairly forthcoming when talking about gaining a history. It is potentially more of an issue in our adolescent patients who are maybe a little bit more nervous about providing some of that history component where something like a urine drug screen might be helpful. And if it's positive for THS in conjunction with a larger picture of other negative testing in the history can be helpful to kind of clue you into what's going on. But like I said, not really needed when folks are telling you, you know, about their normal cannabis use.
Alicia McVity: If the
Dr Leah Middelberg: patient returns with additional episodes of CHS and they've had really reassuring testing in the past and the symptoms are all really consistent with what's happened before, your workup can start to get pared down. It can start to become less. And really at that point, you're looking for complications from that cyclic vomiting or the CHS. Things like electrolyte abnormalities or sometimes even EKGs, which is like that rhythm strip of your heart. Looking for complications of electrolyte changes or even some of the medications that we use to treat CHS.
Dr Leah Middelberg: Every once in a while you may worry about getting something like a chest x-ray because if you're having some chest pain or chest symptoms in addition to after all the vomiting, you may be looking for some other complications. So these episodes, when it's kind of the established diagnosis has already been made in someone, can have somewhat more kind of narrowed in workups. But it is still really important during those episodes to repeat that history and physical, find out if this episode is different from other episodes, right? Because just because a person has had CHS before doesn't mean they can't get appendicitis or they can't get pregnant. And so making sure that the history and exam is there every single time.
Alicia McVity: Yeah, Dr. Adkins, what is the treatment for CHS?
Dr Alek Adkins: I think we kind of maybe lose to this a little bit. Probably the biggest treatment is to not use it or to stop using cannabis. But by the time it comes to the emergency department, that's not really our goal. Our goal is to make our patients feel better. And fluids and electrolyte replacement are probably some of the key hallmarks of therapy.
Dr Alek Adkins: Fluid-wise, sometimes we'll add some sugars to the fluid as well, just to kind of help the body out. And then really the big thing is symptom control. See, like Dr. Middleburg alluded to earlier with using hot shower therapy, and it kind of comes back to that TRPV1 protein that's activated with hot water over 109 degrees Fahrenheit and it kind of blunts the pain signaling into the brain is how it works. So there's the nerves on your skin then relay up the signal to the nerves on your spinal cord that relays a signal up to your brain that reduces the pain.
Dr Alek Adkins: That's the same reason why capsaicin cream also works for these cannabis hyperemesis patients. It mimics a hot shower and it desensitizes the nerve endings to help alleviate pain. Another process or thought is that with cannabis use and overstimulation of these endocannabinoids, 1 area in the brain that they get overstimulated is in our center of the brain where you feel hot and cold called the hypothalamus. So 1 thought process is that you are mildly hypothermic with these episodes and that bringing the body temperature up helps you feel better and it helps your body regulate its nausea and vomiting receptors. The other thought is that we call gut steel.
Dr Alek Adkins: So as you're in the hot shower, your blood vessels in your skin are opening up, more blood is going to the skin, and less blood is going to the GI tract, and that is believed to help reduce pain for these patients as well. So those are 2 options to try at home before they come into the hospital. Most of our patients have already tried these options and that's not working, which is why they come and present to us. And so then really kind of the mainstay is anti-medic therapy. And it comes down to which you choose.
Dr Alek Adkins: Do you choose something like odansetron, haloperidol, droperidol, Reglan, compazine? And there have been some studies. There's been a few random control trials, more so in your adult patients. But I think it was the teenagers that can kind of translate pretty well to that Druparidol probably is superior to other anti-medics when it comes to cannabis hyper-MS syndrome. And I always like to explain to families that yes, this medication is sometimes used for patients who are having mental health problems.
Dr Alek Adkins: But there are just as there are a bunch of nerves in the brain, there's also a bunch of nerves in your gut. And those same nerves use the same signaling. And we are instead of using triggering and targeting the brain, we're going to target the gut with these medicines to help with the nausea and the vomiting and abdominal pain. And they looked at different doses of Haldol for it. Seems like the low dose versus high dose are not as much difference.
Dr Alek Adkins: So probably lower is better in these patients. And you can always re-dose them. You can always give more back to them than take things away. And it reduced the length of stay in the hospital, reduced the length of what we call disposition, either to go home or to be admitted. And it also reduced the amount of pain for different follow-up intervals.
Dr Alek Adkins: So I think halodroperidol are also really good options. Obviously with that, there are some complications or things you got to look out for when you're using these medications. Probably the biggest thing everyone think about is certain parts of that EKG get stretched out or get long and we call it the QTC. And there have been some studies that looked at this and about having what we call QTC prolongation, which could potentially put the patient at risk for funny heart rhythms. But it does take a lot more droparadol or even zofran than what we are typically using for these hyperemesis patients.
Dr Alek Adkins: We're talking almost sometimes up to 10 magnified difference before we really are starting to see these dangerous heart dysrhythmia problems in our patients. But I do think, you know, if we're going to do this route, I think it's reasonable to get an EKG just to make sure that we're not priming our patient or putting them at risk. And then just kind of monitoring them while they're on the therapy and they can get really sleepy on the therapy too. So it's always good that they have a good way to get home make sure they didn't bring themselves to the hospital. Sometimes when you're the teenagers they can do that with their driving.
Dr Alek Adkins: We definitely don't want to give someone a medicine like Haldol or Traparadol to make them really sleepy if they brought themselves to the hospital. There's no way for them to get home.
Dr Mike Patrick: Curiously, is that something that then you continue at home? Or is that something, you know, when they get to the point of dehydration and you know, they're really concerned about the vomiting, they come in and you just use it as a one-time thing. But if the symptoms can last several days or a week, you know, do you send them home with Haldol?
Dr Alek Adkins: I do not send them home with how it all a lot of times if you get ahead of it with the how it all prepared at all, it makes them more manageable for symptoms at home with hot showers or so Fran. So I will give them some Zofran to kind of help for rescue doses. But a lot of times if you kind of get really good control of it in the emergency department on the floor, you can kind of dampen down the max, the peak part of the response so they can kind of cope and deal with it at home with sort of what they were doing beforehand. I could kind of describe it as like we're getting you over the hump.
Alicia McVity: So this Dr. Middleburg or Dr. Adkins, you know, just with these kids that come back in or patients that come back in with repeat episodes of CHS, do you use part of that history to find out like which anti-emetic worked for you when you were here last time or what helped control your symptoms the best?
Dr Leah Middelberg: Yeah, definitely. That's part of history. I might ask if they have a known history of coming in with a CHS episode. I'll say, you know, what's kind of worked for you in the past? What have you done at home?
Dr Leah Middelberg: Like Dr. Atkins mentioned, you know, those, these folks are pretty good about trying to get on top of things sometimes at home where they kind of feel that prodrome coming on. Hopefully that process includes cannabis, stopping the cannabis use, because obviously that's only gonna maybe even prolong the process. And so it is helpful to know what's helped for them before and letting a patient know that you're treating, if they are starting to feel better, hey this is the medicine we use this time, just so they can kind of make a mental note of that. And, you know, hopefully, like Dr.
Dr Leah Middelberg: Atkins mentioned, they're starting to kind of recognize that maybe cannabis isn't reacting well for their body, and that maybe it's not something that's going to be part of their future use, or at least not with increased frequency, because obviously their body reacted in a negative way that brought them to the hospital. But if that situation were to occur again, they would at least have some information about what helped them in the past. Yeah.
Alicia McVity: Dr. Adkins, is there a point where you just kind of know like this patient's ready to go home, that they'll do well, or is that something that kind of like they provide you or self-direct when they have that sensation that they're feeling better?
Dr Alek Adkins: Yeah. This is 1 that I noticed that it's really a shared decision making process with the patient. Ideally you want them at the very least to be able to tolerate clear liquids before they're able to go home because if they can't do that, they're going to be right back in the hospital several hours later. So I want to make sure that they are keeping down fluids and ideally that they are keeping down some small amount of bland food. Crackers, bananas, something that's not really light on the stomach And if they're keeping both those things down and the patient feels comfortable going home with some additional nausea, medication for nausea, like Zofran as needed, I think it's very reasonable to send them home.
Dr Alek Adkins: If they're not, then sometimes they have to come in to the hospital and be admitted for overnight in the hospital to really kind of get ahead of all those symptoms. I feel like Dr. Middleburg alluded to, like, it can be 24 plus hours sometimes in these patients to kind of get things under control for them to start feeling better. And it can take several days for them to kind of feel like back to their normal self.
Alicia McVity: Yeah. Dr. Adkins, are there any treatments that should be avoided with CHS?
Dr Alek Adkins: I don't think there's nothing that should be completely avoided. Like I talked about before, just be very mindful when you're kind of mixing your different anti-medics or anti-irritation medicine and just be careful knowing that they all can cause that QT prolongation and that we're keeping an eye on it and we're keeping a close eye on the patient's electrolytes during this process as well. But no, there's nothing that they absolutely cannot have or that would necessarily be deadly or detrimental to their health to go.
Alicia McVity: Okay. Dr. Middleburg, can CHS be treated at home and when should they come to the emergency department for care?
Dr Leah Middelberg: Every 1 is probably a little different. So it really depends on the person. You know, if this is the first episode, I think it's going to be a little bit different. I think with the first episode, these symptoms are pretty dramatic, make you feel really bad really quickly. And so I think the threshold for seeking medical care is probably lower.
Dr Leah Middelberg: If this is a recurrent problem that someone's faced, which happens if someone continues to use cannabis, they may recognize the symptoms, maybe even recognize some of those symptoms in the prodrome phase, that kind of initial I'm just feeling off kind of phase, and they know what care maybe has worked for them in the past, maybe what anti-nausea medicines or that capsaicin cream that Dr. Atkins mentioned, the warm showers, obviously. And if they can stop cannabis use during those prodromal symptoms, potentially they may not escalate to some more severe symptoms. Unfortunately, I don't think we know how many people are self-treating at home, right? There may be a large number of people who are having mild symptoms at home that never come to see me in the emergency department.
Dr Leah Middelberg: And so we don't really know that proportion of who escalates the severe symptoms and needs hospital-based care and who doesn't. You know, the biggest reason that someone with CHS needs hospital care is dehydration and those electrolyte changes. So things like the low blood sugar, changes to your salt or sodium level, Signs of electrolyte changes and dehydration in CHS are really similar to other signs of dehydration and electrolyte changes from other things that cause vomiting. So big decreases in your urine output, really feeling really fatigued and tired, being dizzy, weak, even muscle cramps, headaches, maybe feeling like your heart is racing or beating really fast, and even some numbness or tingling to your hands and feet. So if someone's been doing a lot of the normal things that help them at home, they're starting to progress into some of these symptoms, you know, definitely sounds like someone that might need to be evaluated in the hospital.
Dr Leah Middelberg: And unfortunately, there's not kind of a 1 amount of time I can tell you if you're vomiting for exactly 8 hours and it's not stopped, come back and see me. It kind of is different for everybody based on maybe even their level of hydration prior to this all started, right? But if they're not able to keep fluids down, things are frequently coming up or starting to have those other symptoms, usually it's time to come see me in the emergency department.
Alicia McVity: Yeah. Dr. Middleburg, what are some of the complications with CHS?
Dr Leah Middelberg: So we've kind of talked about some of them here. You know, anytime there's vomiting, there is the risk for those electrolyte changes, dehydration, and sometimes those circumstances can be really dangerous. If you're not able to get any blood sugar in, especially if you're a younger patient, it's sometimes hard for you to mobilize the sugars that your body stores, And so that can be really dangerous and can lead to neurologic effects, so coma, death, things like that. With some electrolyte derangements or kind of those things being off, we can actually see some changes to your heart rhythm and some other complications. But There's other risks to vomiting kind of outside of that.
Dr Leah Middelberg: We actually can sometimes see problems with aspiration, which is vomiting and breathing it in. This can cause irritation to your lungs, something like pneumonitis, which is basically inflammation and irritation in your lungs, and it can also cause pneumonia infection. And we can even see walls or injuries, like I mentioned earlier, to the wall of your esophagus, little tears in the wall of your esophagus that can cause bleeding as you're vomiting, kind of really scary symptoms that the folks are often really alarmed by. And if you have that long-standing nausea, abdominal discomfort, some of the complications are not even just medical, right? It's just interfering with your daily living.
Dr Leah Middelberg: It's interfering with your ability to kind of work effectively or go to school or kind of do all the things that you want to do. I think there's a lot of non-medical complications to consider when you maybe have to go to the hospital frequently, get admitted to the hospital, or before the diagnosis is even made and you don't know what's going on and these symptoms keep happening. There's a lot of testing that could happen. So I think there was actually even 1 study that showed on average patients with CHS incurred like over $75,000 worth of medical costs and up to 5 CT scans and 17 ER visits, really kind of significant things like that before diagnosis is made. And so I think there's a lot of kind of non-physical complications to think of when you're just feeling so crummy for so long.
Alicia McVity: So Dr. Atkins, knowing all of this, is there a way to prevent CHS?
Dr Alek Adkins: I think the best and easiest way to prevent it is to avoid cannabis altogether. Again, that is I think harder to do than I think we give our patients credit for. There is cannabis use disorder similar to other substance use problems, and it's easier said than done to give up cannabis in certain patient populations. And to kind of help with that, sometimes medications, other medications can help with the cessation and stopping use of cannabis. Usually things that are gonna help with your mental health.
Dr Alek Adkins: So we think medications like SSRIs or SNRIs, so things like Zoloft or like fluoxetine or Lexapro, those 4 types of medications. Sometimes medications like imitriptyline in small doses can help as well. There's also kind of a push towards these patients for cognitive behavioral therapy to kind of get down to why they feel the need or the impulse to use cannabis as frequently as they are, to help sort of curb that cannabis use in hopes that it prevents or stops them from getting these hyperemesis episodes. I think if that is the patient's not ready to kind of go down that journey, some other things that the patient can do to help is try to reduce their stress levels, both mental stress as well as physiological stress. Make sure they are seeking mental health help when they're feeling anxious or depressed.
Dr Alek Adkins: Try to encourage them to eat a well-rounded, balanced diet if they can. Other things you could consider for more of what we call a harm reduction model is to change the type of cannabis products or the route of the cannabis product that they're using. Anecdotally, as well as it may have some validity to it, is to switch from inhalation or smoking the product to maybe trying an edible instead. If you feel like you need the cannabis to interact and function, then something like an edible may be easier on the system and the body than smoking the cannabis. Other things are trying to switch from a higher THC concentration down to something that has a more CBD predominant strain, cannabis, or a product that has more CBD involved than the THC component.
Dr Alek Adkins: They sort of balance each other out. And a lot of times these medical marijuana shops and recreational marijuana shops, depending on the state that you're in, will have some amount of label of the THC amount and CBD ratios in the product. So having your patient try to switch to something that has a higher CBD ratio compared to the THC may help with some of these symptoms or stop them altogether, or at least hopefully kind of stop the frequency of these episodes.
Alicia McVity: That's really good information. I imagine that it's, you know, patients that are not open to maybe like discontinuing CANVAS is probably just as important to have them follow up just to kind of recheck in and kind of explore that topic again just to see where the readiness is to discontinue it and maybe seek those other treatments.
Dr Alek Adkins: Exactly.
Alicia McVity: Dr. Atkins, you know there's been an increased passage of recreational cannabis laws. Has this increased the incidence of CHS?
Dr Alek Adkins: I think it's probably a little hard to say, but most likely, yes. Some of these studies are kind of hard to do, right? So in the United States, from a federal level, cannabis is still Schedule 1 substance. And so because of that, some patients are still pretty leery about disclosing that they're using cannabis. So it can be hard to know exactly what percentage of the population actually has cannabis hyperemesis syndrome.
Dr Alek Adkins: There's been some reports that estimate up to 16% or 30% of cannabis users may have some amount of cannabis hyperemesis syndrome. There was a recent study from New York that showed that maybe up to 2.75 million Americans may suffer to some degree of cannabis hyperemesis syndrome. Dr. Middleburg talked about it earlier, but cannabis hyperemesis has been around since the early 2000s. The sort of land-breaking article that described it came out in 2004.
Dr Alek Adkins: Even back in that article, and this was done in Australia, that they attributed to them being able to describe this is because Australia had more lax laws around cannabis use compared to other countries. And so that's why it's probably been around for quite some time. It's just we are able to actually study it and quantify it. There have been a study in Canada as well that has looked at pre legalization and post legalization, and there has been an increase in ER visits for cannabis hyperemesis. So it's definitely, we've seen these uptricks in other states, in other countries, and I anticipate in America it's probably the same.
Dr Alek Adkins: It's probably gonna be a little more time than before we can actually quantify the exact incidence of how much is actually rising with the legalization or decriminalization, I guess I should say.
Dr Mike Patrick: Yeah, and I wanna point out too, since we have an audience of pediatric providers and we're talking about cannabis and We have a toxicologist here with us. I just wanted to ask a quick question regarding acute intoxication with cannabis, especially in kids. And as we think about the legalization and there's just more cannabis products in the home, Are we seeing an uptick in acute intoxication, especially among kids?
Dr Alek Adkins: I would say yes, we are seeing more acute intoxications with kids. And I think part of it is, when people think about cannabis use and the being stoned and being intoxicated from cannabis. They think of the adolescents and adults and they kind of translate that into children. But I think as most pediatricians know that kids are not just little adults and their bodies and their pathophysiology can be very different. And cannabis and our young patients, especially kids under age of 6, it can be deadly, cannabis exposure can be.
Dr Mike Patrick: And when you think about the edibles, there's really a delay in the onset of symptoms compared to smoking it. And you have a bag of gummies, for example, and they're colorful, they taste like candy, they don't necessarily have an effect right away. It'd be really easy for young kids just to open up the bag and eat several of those. And then when they do start to take effect, I mean, you can have respiratory depression and unconsciousness, and as you said, it can be life-threatening.
Dr Alek Adkins: Not only kids find these edibles super delicious, but so do adults, and we are seeing probably more adults with accidental overdoses because they do not realize just how potent their edibles were or they did not realize how long it was going to take for the symptoms to happen and then it's already too late and because it can be delayed by several hours.
Dr Mike Patrick: Yeah, in fact I saw a kid just recently who was like, I ate 1 and I didn't feel anything. So I had another 1 and I still didn't feel anything. So I had a third 1 and a fourth 1. And you know, we found out that story once she woke up, which took quite a while.
Dr Leah Middelberg: The packaging can be really confusing. Like Dr. Atkins mentioned, in for adults, sometimes the packaging can look like the normal treat that you might want from the store. And so there can be inadvertent purchasing and ingestion or eating for adults just because it can be really deceiving.
Dr Mike Patrick: And a lot of times it'll have the amount of THC in the entire package, but that doesn't tell you how much is in each 1 of them and that can further confuse things.
Dr Alek Adkins: Or sometimes it's per piece and patients think that it is per package as well with these small pieces.
Dr Mike Patrick: There's no standardization in any of this.
Dr Alek Adkins: And there's really no regulations that they have to put the strength on their products either. So you're kind of taking it at the manufacturer's word when you're reading these labels.
Dr Mike Patrick: Well, this has been a very interesting conversation, and I'm just so thankful for all of you for bringing it to us, because it's something that we are certainly, at least here in Ohio, we are gonna see more and more of with the legalization of recreational marijuana use. And so I think it's something that providers everywhere really do need to kind of sharpen up on and have it in the back of our minds when we're seeing folks who come in the cue episodes of vomiting, at least to put it in the differential and certainly not assume that's what it is, even if that has happened in a particular patient in the past. So many good, good things said during this interview. So once again, Alec Adkins with toxicology at Nationwide Children's Hospital and Leah Middleburg with Emergency Medicine and Alicia, thank you so much. You did a fantastic job putting this together.
Dr Mike Patrick: Alicia came up with our learning objectives, our interview questions, she wrote the post-test and just really put a lot of hard work into this episode. And so we are all very appreciative to all of you. Thanks so much.
Alicia McVity: I appreciate being here. Thank you so much.
Dr Leah Middelberg: Thank you guys for focusing on this topic. I think it's under-recognized and so I'm thankful that you guys are getting this information out there.
Dr Alek Adkins: Thank you so much for having me here. It's been wonderful talking with everyone.
Dr Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PDA Cast CME a part of it. Really do appreciate that. Thanks again to our guests this week, Dr. Leah Middleburg with Emergency Medicine and Dr. Alec Adkins with toxicology, both at Nationwide Children's Hospital.
Dr Mike Patrick: And thanks so much to our guest host this week, Alicia McVeighty. Don't forget you can find us wherever podcasts are found. We're in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, YouTube, and most other podcast apps for iOS and Android. Our landing site is pdacastcme.org. You'll find our entire archive of past programs there, along with show notes for each of the episodes, our continuing medical education information, our terms of use agreement and that handy contact page.
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Dr Mike Patrick: So you've listened to the podcast, now be sure to claim your free Category 1 Continuing Medical Education credit. Easy thing to do, simply head over to the show notes for this episode at pediacastcme.org. You'll find a link to the post-test in the show notes. Follow that link to CloudCME. You'll need to click on the materials link and then take and pass the post-test and the category 1 credit is yours.
Dr Mike Patrick: Super easy, right? And again, we offer credit to many pediatric professionals, including doctors, of course, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. Of course, you want to be sure the content of this episode matches your scope of practice. Complete details are available at pediacastcme.org. We also have a podcast for moms and dads and lots of pediatricians and other providers also tune into that 1.
Dr Mike Patrick: We just don't actually provide accredited CME credit for those. But we do cover pediatric news, we answer listener questions, and we interview pediatric and parenting experts. Shows are available at the landing site for that program over at pediacast.org. Also available wherever podcasts are found, simply search for Pediacast. Thanks again for stopping by and until next time, this is Dr.
Dr Mike Patrick: Mike saying stay informed, keep it evidence-based, and take care of those kids. So long, everybody.
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