Marijuana hyperemesis syndrome

[miacomet]

We see a lot of patients with this. How do others treat it? Hot shower in the decon room? Haldol?

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[deleted859535]

We see a lot of patients with this. How do others treat it? Hot shower in the decon room? Haldol?

Antiemetics routinely, then Haldol.

Capsaicin cream is starting to make the rounds here.

 

[miacomet]

Antiemetics routinely, then Haldol.

Capsaicin cream is starting to make the rounds here.

Do you have capsaicin cream in the ER? Or just launch the patient with instructions?

 

[Psai]

Order a bunch. Have the patients rub it on their chest. Easy discharge in 30 minutes and watch those press ganey scores soar

 

[BoardingDoc]

Do you have capsaicin cream in the ER? Or just launch the patient with instructions?

Have it in the ED. I ask them if hot showers help them. If yes, they get the cream. They can leave with the tube and a warning not to rub their eyes/crotch. If showers don't help, zofran. If zofran doesn't work, 2-4 of IV haldol depending on size.

 

[southerndoc]

Haloperidol is the first-line agent for CHS if I suspect it.

 

[MechEDoc]

No cream where I work. 5 mg Haldol IV. Then I give them the following instructions:

You were diagnosed with cannabinoid hyperemesis syndrome.

• This is a condition in which a patient often has severe vomiting after long-term use of marijuana.
• The only treatment of cannabinoid hyperemesis syndrome is to stop using marijuana. Some patients say that their symptoms get better by taking a hot shower, but this is just a temporary fix.
• You are safe to go home. It is important to stop using marijuana to help resolve your nausea, vomiting, and belly pain.
• We don’t think your condition is dangerous right now. Still, it is important to be careful. Sometimes a problem that seems small can get serious later. This is why it is very important to come back here or go to the nearest Emergency Department if you don t get better or your symptoms get worse.

YOU SHOULD SEEK MEDICAL ATTENTION IMMEDIATELY, EITHER HERE OR AT THE NEAREST EMERGENCY DEPARTMENT, IF ANY OF THE FOLLOWING OCCUR:

• Worsening pain. If your pain does not go away in the next 12-24 hours please return to the emergency department or see your primary care physician promptly.
• You cannot keep fluids down or if you are vomiting dark green material, coffee ground like material, or bright bloody material.
• If you have bloody bowel movements or bowel movements that are dark and tar like.
• If you are unable to pass flatus (gas) or stool for more than 8 hours.
• If you have a fever > 100.4ºF or shaking chills.
• If you have yellow skin or eyes or dark brown urine.
• If your pain moves to the right lower corner ("quadrant") of your abdomen.
• If you are light headed upon standing or passing out.
• Many things can cause abdominal pain. Examples include viral infections and bowel (intestine) spasms. You might need another examination or more tests to find out why you have pain.
• If you are otherwise concerned about your health.

 

[deleted859535]

Do you have capsaicin cream in the ER? Or just launch the patient with instructions?

We can get it, but I haven't used it a whole lot quite yet.

 

[LaBusqueda]

Yea. I go to haldol, even IM, so fast now a days. IV ordered cap crm but I have. Or ordered it solo yet.


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[Groove]

I hadn't even heard about capsaicin treatment until hearing it on an EMRAP podcast a few months ago. Since then, I've had opportunity to try it out about twice and it worked both times. I rub a handful on their tummy or have the nurse do it and both responded within about 30 mins. I'm not sold yet, but so far it's promising. I used to use haldol. I try to isolate pt's that are convincing for hyperemesis cannabinoid syndrome and not gastroparesis or some cyclical vomiting variant. If there's other stuff going on, I don't use it.

 

[WilcoWorld]

Droperidol if ya got it, Haldol if ya don't.

Pro tip: explain the plan of care to the nurses so they don't walk in and say "I have an antipsychotic for you" & explain to the patients so that they understand this is a "potent anti-nausea" medicine.

These are actually pretty satisfying cases for me most of the time. It works wonders, kinda like ketorolac in renal colic.

 

[miacomet]

Thanks for all the responses! I will check on our capsaicin supply...

Interestingly, I had a dude who's primary had prescribed PO haldol for his hyperemesis and he came in with, you guessed it, a dystonic reaction. Pretty hilarious price to pay as opposed to quitting weed!

 

[d2305]

I used po promethazine, which I've never seen a dystonic reacton or NMS. Guess is does happen though.

 

[miacomet]

Thanks for all the responses. I have requested that my hospital stock capsaicin cream.

 

[Birdstrike]

I hadn't even heard about capsaicin treatment until hearing it on an EMRAP podcast a few months ago. Since then, I've had opportunity to try it out about twice and it worked both times. I rub a handful on their tummy or have the nurse do it and both responded within about 30 mins. I'm not sold yet, but so far it's promising. I used to use haldol. I try to isolate pt's that are convincing for hyperemesis cannabinoid syndrome and not gastroparesis or some cyclical vomiting variant. If there's other stuff going on, I don't use it.

Capsaicin can also work for post herpetic neuralgia.

 

[throckmortonDO]

IV haldol? I don't do that because of the black box warning, the fact that IV is a route non-approved by the FDA, and a famous lawsuit involving IV haldol.

I use 2-5mg IM haldol +/- benadryl/ativan IM
Benzos have good antiemetic effects, and the benadryl helps with the akithesias etc
Yes, I know it's like a B52, but - has been working for me.
Also works good for cyclic vomiters that are not cannabinoid hyperemesis.

We haven't been able to get droperidol for years - but that used to be really good too.

 

[southerndoc]

I also don't give haloperidol IV. One of my medics did that to an alcoholic high on cocaine. Didn't end well.

 

[TooMuchResearch]

We use IV Haldol and Zyprexa routinely, did it in residency too.

 

[deleted859535]

I also don't give haloperidol IV. One of my medics did that to an alcoholic high on cocaine. Didn't end well.

Ooh. What happened there?

 

[southerndoc]

NMS. Spent a month in the ICU. Paramedic decided to ignore what I had written in the protocol (see below). Paramedic was terminated.

If chemical sedation is required, administer (may administer one only):
a. Ketamine 1 mg/kg IM (not to exceed 200 mg). May repeat once in 5 minutes if no relief.
Requires supplemental oxygen and continuous cardiac monitoring
b. Midazolam (Versed) 2-5 mg IV/IM/IN AND Haloperidol (Haldol) 2.5-5 mg IM. Do not
administer haloperidol IV.

and this at the bottom of the protocol:

NOTE: The lowest effective dose of haloperidol and midazolam should be used (e.g.,
midazolam 2 mg IM and haloperidol 2.5 mg IM) if possible and should be titrated to body habitus and
degree of agitation/psychosis. Haloperidol should not be administered in patients with known
prolonged QT syndrome or with a family history of prolonged QT. Haloperidol administration is NOT
approved for IV administration. Any administration of chemical
restraint requires notification to the medical director within 24 hours for review.

 

[WilcoWorld]

NMS. Spent a month in the ICU. Paramedic decided to ignore what I had written in the protocol (see below). Paramedic was terminated.

If chemical sedation is required, administer (may administer one only):
a. Ketamine 1 mg/kg IM (not to exceed 200 mg). May repeat once in 5 minutes if no relief.
Requires supplemental oxygen and continuous cardiac monitoring
b. Midazolam (Versed) 2-5 mg IV/IM/IN AND Haloperidol (Haldol) 2.5-5 mg IM. Do not
administer haloperidol IV.

and this at the bottom of the protocol:

NOTE: The lowest effective dose of haloperidol and midazolam should be used (e.g.,
midazolam 2 mg IM and haloperidol 2.5 mg IM) if possible and should be titrated to body habitus and
degree of agitation/psychosis. Haloperidol should not be administered in patients with known
prolonged QT syndrome or with a family history of prolonged QT. Haloperidol administration is NOT
approved for IV administration. Any administration of chemical
restraint requires notification to the medical director within 24 hours for review.

Huh, I had guessed it was going to be cardiac arrest, because the patient had an underlying prolonged QT from severe hypomagnesemia/hypokalemia that was worsened by the cocaine, then tipped over by the haldol.

Is there a difference in rates of NMS when haloperidol is given IV rather than IM? I wasn't aware of any such difference.

 

[Fox800]

Huh, I had guessed it was going to be cardiac arrest, because the patient had an underlying prolonged QT from severe hypomagnesemia/hypokalemia that was worsened by the cocaine, then tipped over by the haldol.

Is there a difference in rates of NMS when haloperidol is given IV rather than IM? I wasn't aware of any such difference.

Agreed, please enlighten us. We routinely give it IV at our hospital, sometimes in quite high doses for refractory agitation.

 

[southerndoc]

@Fox800 Not sure about worsening NMS. My paramedics aren't allowed (and I don't administer it) to give it IV because of QT prolongation and risk of TdP. The last thing I want to do is cause our hospital to take it away like droperidol.

 

[alpinism]

Give IV haldol 5-10mg almost every day.

Never had a problem with NMS.

 

[Zebra Hunter]

1mg/kg of IM ketamine for sedation is an ineffective dose, as well. Recommendation is for 3-5mg/kg IM dosing, although I stick to 3mg/kg.

 

[southerndoc]

1mg/kg of IM ketamine for sedation is an ineffective dose, as well. Recommendation is for 3-5mg/kg IM dosing, although I stick to 3mg/kg.

These are paramedics using it for chemical restraint. I don't want them conscious sedating someone. I just want the person to chill out until they can come to the ER to be evaluated. No sense in arriving to the ER comatose after their 4 mg/kg IM dose so they can wait a while before being evaluated.

 

[TooMuchResearch]

We use IV Haldol and Zyprexa routinely, did it in residency too.

It's also approved by P&T.

 

[TooMuchResearch]

These are paramedics using it for chemical restraint. I don't want them conscious sedating someone. I just want the person to chill out until they can come to the ER to be evaluated. No sense in arriving to the ER comatose after their 4 mg/kg IM dose so they can wait a while before being evaluated.

If they're using ketamine, I prefer the patient to come in completely dissociated so we can transfer them to our bed, search them, and let them wake up to see how they're feeling. I don't want a half agitated, somewhat dissociated person. Personal preference I guess.

 

[Birdstrike]

Yes, some black-box warnings are overdone, but just give haldol IM. What's the big deal? What, you're afraid you might have to wait 10 extra minutes for onset?

Meh.

If you need something faster than that, there are other choices that aren't such tasty lawyer-bait.

Oh, wait....

Wait. Are there still people that think lawyers, box checkers, insurance companies, patients and government bureaucrats don't actually tell us how to practice medicine?

Hmm...Weird.

 

[Interpolfanclub]

A lot of this is probably institutional or personal preference. I routinely give haldol IV for agitation. Loved droperidol too before that disappeared from every hospital everywhere.

 

[Hamhock]

and a famous lawsuit involving IV haldol..

I'm not familiar with this. I started to Google, but got a bunch of junk.
What case are you referring too?
HH

 

[Vandalia]

I'm not familiar with this. I started to Google, but got a bunch of junk.
What case are you referring too?
HH

The only thing I can think of is the "Libby Zion" case out of New York that was the impetus for the restrictions on resident hours. While that eventually involved Haldol, I think there were many other factors that were more important in that case.

Libby Zion Law - Wikipedia

But maybe there is another case out there that they are referring to.

 

[alpinism]

1mg/kg of IM ketamine for sedation is an ineffective dose, as well. Recommendation is for 3-5mg/kg IM dosing, although I stick to 3mg/kg.

Agreed.

Giving 1mg/kg IM will just put them in the sub dissociative range and make them even more violent and agitated.

The ACEP excited delirum task force recommends 4-5mg/kg IM for ketamine.

http://www.fmhac.net/Assets/Documents/2012/Presentations/KrelsteinExcitedDelirium.pdf