LO48: Pediatric cannabinoid hyperemesis syndrome in the emergency department: a 5-year retrospective review

Introduction: Cannabinoid Hyperemesis Syndrome (CHS) in pediatric patients is poorly characterized. Literature is scarce, making identification and treatment challenging. This study's objective was to describe demographics and visit data of pediatric patients presenting to the emergency department (ED) with suspected CHS, in order to improve understanding of the disorder. Methods: A retrospective chart review was conducted of pediatric patients (12-17 years) with suspected CHS presenting to one of two tertiary-care EDs; one pediatric and one pediatric/adult (combined annual pediatric census 40,550) between April 2014-March 2019. Charts were selected based on discharge diagnosis of abdominal pain or nausea/vomiting with positive cannabis urine screen, or discharge diagnosis of cannabis use, using ICD-10 codes. Patients with confirmed or likely diagnosis of CHS were identified and data including demographics, clinical history, and ED investigations/treatments were recorded by a trained research assistant. Results: 242 patients met criteria for review. 39 were identified as having a confirmed or likely diagnosis of CHS (mean age 16.2, SD 0.85 years with 64% female). 87% were triaged as either CTAS-2 or CTAS-3. 80% of patients had cannabis use frequency/duration documented. Of these, 89% reported at least daily use, the mean consumption was 1.30g/day (SD 1.13g/day), and all reported ≥6 months of heavy use. 69% of patients had at least one psychiatric comorbidity. When presenting to the ED, all had vomiting, 81% had nausea, 81% had abdominal pain, and 30% reported weight loss. Investigations done included venous blood gas (30%), pregnancy test in females (84%), liver enzymes (57%), pelvic or abdominal ultrasound (19%), abdominal X-ray (19%), and CT head (5%). 89% of patients received treatment in the ED with 81% receiving anti-emetics, 68% receiving intravenous (IV) fluids, and 22% receiving analgesics. Normal saline was the most used IV fluid (80%) and ondansetron was the most used anti-emetic (90%). Cannabis was suspected to account for symptoms in 74%, with 31% of these given the formal diagnosis of CHS. 62% of patients had another visit to the ED within 30 days (prior to or post sentinel visit), 59% of these for similar symptoms. Conclusion: This study of pediatric CHS reveals unique findings including a preponderance of female patients, a majority that consume cannabis daily, and weight loss reported in nearly one third. Many received extensive workups and most had multiple clustered visits to the ED.

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75 Paediatric Cannabinoid Hyperemesis Syndrome in the Emergency Department: a 5-year Retrospective Review

Paediatrics & Child Health ◽

10.1093/pch/pxaa068.074 ◽

2020 ◽

Vol 25 (Supplement_2) ◽

pp. e31-e31

Author(s):

Daniel Foster ◽

Kristine Van Aarsen ◽

Justin Yan ◽

John Teefy ◽

Tim Lynch

Keyword(s):

Emergency Department ◽

Weight Loss ◽

Abdominal Pain ◽

Venous Blood ◽

Tertiary Care ◽

Retrospective Chart Review ◽

Cannabis Use ◽

Discharge Diagnosis ◽

Paediatric Patients ◽

Cannabinoid Hyperemesis Syndrome

Abstract Background Cannabinoid Hyperemesis Syndrome (CHS) in paediatric patients is poorly characterized. Identification and treatment of adolescents presenting to the emergency department (ED) for suspected CHS is challenging. Given the paucity of literature on paediatric CHS and the recent legalization of cannabis, it is important to gain a better understanding of this disorder. Objectives The objective of this study was to describe demographics and ED visit data of paediatric patients presenting to the ED with suspected CHS. Design/Methods A retrospective chart review was conducted of paediatric patients (12-17 years) with suspected CHS presenting to one of two tertiary-care EDs; one paediatric (annual census 38,500) and one paediatric and adult (annual census 60,000) between April 2014-March 2019. Charts were selected based on discharge diagnosis of abdominal pain or nausea/vomiting with positive cannabis urine screen, or discharge diagnosis of cannabis use, using ICD-10 codes. Patients with confirmed or likely diagnosis of CHS were identified and data including demographics, clinical history, and ED investigations/treatments were recorded by a trained research assistant. Results A total of 242 patients met criteria for review. Thirty-nine were identified as having a confirmed or likely diagnosis of CHS (mean age 16.2, SD 0.85 years with 64% female), 87% were triaged as either CTAS-2 or CTAS-3 and 80% of patients had cannabis use frequency/duration documented. Of these, 89% reported at least daily use, the mean consumption was 1.30g/day (SD 1.13g/day), and all reported ≥6 months of heavy use. Sixty-nine percent of patients had at least one psychiatric comorbidity. When presenting to the ED, all had vomiting, 81% had nausea, 81% had abdominal pain and 30% reported weight loss. Investigations done included venous blood gas (30%), pregnancy test in females (84%), liver enzymes (57%), pelvic or abdominal ultrasound (19%), abdominal X-ray (19%), and CT head (5%). Eighty-nine percent of patients received treatment in the ED with 81% receiving anti-emetics, 68% receiving intravenous fluids, and 22% receiving analgesics. Normal saline was the most used intravenous fluid (80%) and ondansetron was the most used anti-emetic (90%). Cannabis was suspected to account for symptoms in 74% (with 31% of these given the formal diagnosis of CHS). Sixty-two percent of patients had another visit to the ED within 30 days (59% of these for similar symptoms). Conclusion This study of paediatric CHS reveals unique findings including a preponderance of female patients, a majority that consume cannabis daily, and weight loss reported in nearly 1/3rd. Many received extensive workups and most had multiple clustered visits to the ED.

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LO28: Emergency department gastrointestinal presentations related to marijuana ingestion: a single centre retrospective study

CJEM ◽

10.1017/cem.2019.71 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S17

Author(s):

J. Teefy ◽

J. Blom ◽

K. Woolfrey ◽

M. Riggan ◽

J. Yan

Keyword(s):

Emergency Department ◽

Abdominal Pain ◽

Tertiary Care ◽

Retrospective Chart Review ◽

Clinical History ◽

Cannabis Use ◽

Future Research ◽

Discharge Diagnosis ◽

Marijuana Consumption ◽

The Impact

Introduction: Cannabis Hyperemesis Syndrome (CHS) is a poorly understood phenomenon with a subset of patients presenting to the emergency department (ED) for symptomatic control of refractory nausea and vomiting. As legalization of marijuana commenced on October 2018, it is important to recognize the presentation of patients related to marijuana consumption. The objective of this study was to describe demographic and ED visit data of patients presenting to the ED with cannabis-related sequelae. Methods: This was a health records review of patients ≥18 years presenting to one of two tertiary care EDs (annual census 150,000 visits) with a discharge diagnosis including cannabis use with one of abdominal pain or nausea/vomiting using ICD-10 codes. Trained research personnel collected data from medical records including demographics, clinical history, results of investigations within the ED. Descriptive statistics including means and standard deviations are presented where appropriate. Results: From April 2014 to June 2016, 203 unique ED patients had a discharge diagnosis including cannabis use with abdominal pain or nausea/vomiting. Mean (SD) age was 30 (13.04) years and 120 (59.1%) were male. Patients presented to the ED independently 84 (41.4%), via EMS with 104 (51.23%) and 15 (7.39%) by police. The majority of patients were triaged as CTAS-2 in 27 (33%) and CTAS-3 in 106 (52.2%) of all cases. Of patients disclosing their method of consumption, 31 (15.3%) had used combustion methods and 30 (14.8%) had edible marijuana. Mean (SD) serum potassium was 3.71 (0.48) mmol/l. 162 (79.8%) were discharged home and 9 (4.4%) were given follow up (all psychiatric). Twenty-nine (14.3%) were admitted to hospital with 28 (13.8%) admitted to psychiatry and 1 (0.5%) admitted to medicine. Conclusion: This ED-based retrospective chart review reports a description of cannabis-related presentations to the ED. Clinicians should be aware of CHS in patients presenting to the ED, especially as Canada enters the era of legalization. Future research should focus on the impact of federal legalization of marijuana on ED utilization for CHS-related presentations.

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Cannabinoid hyperemesis syndrome presentation to the emergency department: A two-year multicentre retrospective chart review in a major urban area

CJEM ◽

10.1017/cem.2017.381 ◽

2017 ◽

Vol 20 (4) ◽

pp. 550-555 ◽

Cited By ~ 8

Author(s):

Jeremy M. Hernandez ◽

Jared Paty ◽

Ira M. Price

Keyword(s):

Emergency Department ◽

Tertiary Care ◽

Case Series ◽

Retrospective Chart Review ◽

Kappa Statistic ◽

Cannabis Use ◽

Urgent Care ◽

Care Centre ◽

Tertiary Care Centre ◽

Cannabinoid Hyperemesis Syndrome

AbstractObjectiveCannabinoid hyperemesis syndrome (CHS) is a paradoxical side effect of cannabis use. Patients with CHS often present multiple times to the emergency department (ED) with cyclical nausea, vomiting, and abdominal pain, and are discharged with various misdiagnoses. CHS studies to date are limited to case series. The objective was to examine the epidemiology of CHS cases presenting to two major urban tertiary care centre EDs and one urgent care centre over a 2-year period.MethodsUsing explicit variables, trained abstractors, and standardized abstraction forms, we abstracted data for all adults (ages 18 to 55 years) with a presenting complaint of vomiting and/or a discharge diagnosis of vomiting and/or cyclical vomiting, during a 2-year period. The inter-rater agreement was measured using a kappa statistic.ResultsWe identified 494 cases: mean age 31 (+/-11) years; 36% male; and 19.4% of charts specifically reported cannabis use. Among the regular cannabis users (>three times per week), 43% had repeat ED visits for similar complaints. Moreover, of these patients, 92% had bloodwork done in the ED, 92% received intravenous fluids, 89% received antiemetics, 27% received opiates, 19% underwent imaging, 8% were admitted to hospital, and 8% were referred to the gastroenterology service. The inter-rater reliability for data abstraction was kappa=1.ConclusionsThis study suggests that CHS may be an overlooked diagnosis for nausea and vomiting, a factor that can possibly contribute to unnecessary investigations and treatment in the ED. Additionally, this indicates a lack of screening for CHS on ED history, especially in quantifying cannabis use and eliciting associated symptoms of CHS.

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P060: Cannabinoid hyperemesis syndrome presentation to the emergency department: a two-year multi-centre retrospective study

CJEM ◽

10.1017/cem.2016.236 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S98-S99 ◽

Cited By ~ 2

Author(s):

J.M. Hernandez ◽

J. Paty ◽

I. Price

Keyword(s):

Emergency Department ◽

Tertiary Care ◽

Case Series ◽

Kappa Statistic ◽

Cannabis Use ◽

Data Abstraction ◽

Tertiary Care Centre ◽

Associated Symptoms ◽

Cannabinoid Hyperemesis Syndrome ◽

Ed Visits

Introduction: Cannabinoid hyperemesis syndrome (CHS) is a paradoxical side effect of cannabis use. Patients with CHS often present multiple times to the Emergency Department (ED) with cyclical nausea, vomiting and abdominal pain, and are discharged with various misdiagnoses. CHS studies to date are limited to case series. We examined the epidemiology of CHS cases presenting to two major urban Tertiary Care Centre EDs. Methods: Using explicit variables, trained abstractors, and standardized abstraction forms, we abstracted data for all adults (18-55 years) with a presenting complaint of vomiting, and/or a discharge diagnosis of vomiting and/or cyclical vomiting, during a 2-year period. Inter-rater agreement was measured using a kappa statistic. Results: We identified 494 cases: mean age 31 years; 36% male; only 19.4% of charts specifically reported cannabis use. Among the regular cannabis users (>3 times per week), 43% had repeat ED visits for similar complaints. Interestingly, of these patients, 92% had bloodwork done in the ED, 92% received IV fluids, 89% received anti-emetics, 27% received opiates, 19% underwent imaging, 8% were admitted to hospital, and 8% were referred to the Gastroentorology service. Inter-rater reliability for data abstraction was kappa = 1. Conclusion: This study suggests CHS may be an overlooked diagnosis for nausea and vomiting, a factor which can possibly contribute to unnecessary investigations and treatment in the ED. Additionally, this indicates a lack of screening for CHS on ED history, especially in quantifying cannabis use and eliciting associated symptoms of CHS.

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P128: Describing variability in treatment of THC hyperemesis in the emergency department: a health records review

CJEM ◽

10.1017/cem.2019.319 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S110

Author(s):

J. Teefy ◽

J. Blom ◽

K. Woolfrey ◽

M. Riggan ◽

J. Yan

Keyword(s):

Abdominal Pain ◽

Tertiary Care ◽

Symptomatic Treatment ◽

Cannabis Use ◽

Treatment Modalities ◽

Future Research ◽

Discharge Diagnosis ◽

First Line ◽

Health Records ◽

Opioid Medications

Introduction: Cannabis Hyperemesis Syndrome (CHS) is a new and poorly understood phenomenon with a subset of patients presenting to emergency departments (ED) for symptomatic control of their refractory nausea and vomiting. Curently, there is a lack of agreement and considerable practice variability on initial treatment modalities for CHS. The objective of this study was to describe the treatment modalities for patients presenting to ED with cannabis-related sequelae. Methods: This was a health records review of patients ≥18 years presenting to one of two tertiary care EDs (annual census: 150,000) with a discharge diagnosis including cannabis use with one of abdominal pain or nausea/vomiting using ICD-10 codes. Trained research personnel collected data from medical records including demographics, clinical history, results of investigations, and utilization of treatment options within the ED. Descriptive statistics are presented where appropriate. Results: From April 2014 to June 2016, 203 unique ED patients had a discharge diagnosis including cannabis use with abdominal pain or nausea/vomiting. Sixty-nine (33.4%) received any treatment during their visit with 28 (40.6%) receiving IV fluids, of which 24 (85.7%) received normal saline. Anti-emetics were used in 21 (30.4%) patients with ondansetron being the first-line agent in 11 (52.4%) patients followed by dimenhydrinate in 6 (28.6%) and haloperidol in 2 (9.5%) cases. Six patients required two doses of anti-emetics, favouring ondansetron in 3 cases followed by haloperidol, dimenhydrinate, and metoclopramide each used once. Thirteen (19%) patients required analgesia, with the first-line preference being non-opioid medications in 11 versus opioids in 2 cases. Seven patients required multiple modes of analgesia, favouring opioid medications in 4 patients. Twenty-eight (40.6%) patients required anxiolytics with lorazepam being used primarily in 16 (57.1%) patients followed by lorazepam/haloperidol in 5 (17.9%) cases. Conclusion: This ED-based study demonstrates variability of practice patterns for symptomatic treatment of cannabis related ED presentations. Despite knowledge of haloperidol being useful in patients with suspected CHS, physicians opted for ondansetron as first line anti-emetics. Future research should focus on studying various treatment modalities of patients with suspected CHS in the ED to optimize symptomatic treatment.

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Cannabinoid Hyperemesis Syndrome: A Case Report of an Underdiagnosed Condition

GE Portuguese Journal of Gastroenterology ◽

10.1159/000512088 ◽

2020 ◽

pp. 1-5

Author(s):

João Machado Nogueira ◽

Inês Fonseca ◽

Marco Duarte

Keyword(s):

Emergency Department ◽

Abdominal Pain ◽

Diagnostic Tests ◽

Clinical Symptoms ◽

Definitive Diagnosis ◽

Hot Water ◽

Illustrative Case ◽

Raising Awareness ◽

Detailed Medical History ◽

Cannabinoid Hyperemesis Syndrome

Cannabinoid hyperemesis syndrome (CHS) is characterized by episodic bursts of nausea, vomiting and abdominal pain, affecting chronic cannabis users. The clinical picture mimics an acute abdomen, usually leading to multiple assessments in the emergency department. Several complementary diagnostic examinations are performed with non-specific results, making differential diagnosis puzzling. We present a case of a 42-year-old man, who has been admitted multiple times to the emergency department in the last 3 months for abdominal pain, nausea and vomiting, without triggering factors and improving only with hot water baths. He was evaluated by different specialties, the various complementary diagnostic tests performed showed no significant results, and no definitive diagnosis was obtained. Treatment resulted only in a partial and transient resolution of symptoms. A more detailed medical history revealed cannabis use for more than 5 years, with a recent increase in the amount consumed. After psychoeducation, explaining the risks associated with consumption and its relationship with the clinical symptoms, which resulted in complete suspension of cannabis, there have been no new symptomatic episodes since then. We present an illustrative case of a poorly reported clinical entity despite having a probable significant prevalence, raising awareness in order that clinicians identify and properly manage these cases.

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Feasibility and Success of Hiv Point-of-Care Testing in an Emergency Department in an Urban Canadian Setting

Canadian Journal of Infectious Diseases and Medical Microbiology ◽

10.1155/2013/164797 ◽

2013 ◽

Vol 24 (1) ◽

pp. 27-31 ◽

Cited By ~ 15

Author(s):

Marissa L Becker ◽

Laura H Thompson ◽

Carla Pindera ◽

Natalie Bridger ◽

Carmen Lopez ◽

...

Keyword(s):

Emergency Department ◽

Hiv Testing ◽

Point Of Care ◽

Venous Blood ◽

Tertiary Care ◽

Antibody Test ◽

Cross Sectional Study ◽

Cross Sectional ◽

Post Test ◽

Centre Hospital

BACKGROUND: Approximately 26% of Canadians living with HIV are unaware of their status. Point-of-care (POC) HIV tests have been introduced to simplify and expand HIV testing.OBJECTIVE: To evaluate the feasibility and acceptability of POC testing in an emergency department (ED) setting in Winnipeg, Manitoba.METHODS: A cross-sectional study of unselected adults presenting to the ED at the Health Sciences Centre Hospital (Winnipeg, Manitoba) was performed. Study procedures included pre- and post-test counselling, administration of the INSTI HIV-1/HIV-2 Antibody Test (bioLytical Laboratories, Canada) and a brief questionnaire. Venous blood samples were collected from participants for confirmatory testing on all reactive and indeterminate specimens.RESULTS: In total, 501 adults participated in the study. The majority of participants were younger than 40 years of age, approximately one-half (48.5%) were women and 53% self-identified as Aboriginal. Nearly one-half (49.1%) of the participants had undergone previous HIV testing, although 63% of these tests were performed more than a year earlier. A total of seven individuals tested reactive with the POC test, all of whom were confirmed positive using serological testing (1.4%) and were linked to an HIV specialist within 24 h. Nearly all of the participants (96%) reported satisfaction with the test and believed it belonged in the ED (93%).CONCLUSIONS: Of the participants tested, 1.4% tested reactive for HIV, which is significantly higher than the reported prevalence in Manitoba and in other similar studies conducted in North America. Furthermore, all individuals were linked to timely care. The present study demonstrated that this particular busy tertiary care ED is an important and feasible location for HIV POC testing.

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Diagnostic Accuracy of Neurological Problems in the Emergency Department

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100008921 ◽

2008 ◽

Vol 35 (3) ◽

pp. 335-341 ◽

Cited By ~ 44

Author(s):

Jeremy J Moeller ◽

Joelius Kurniawan ◽

Gordon J Gubitz ◽

John A Ross ◽

Virender Bhan

Keyword(s):

Emergency Department ◽

Diagnostic Accuracy ◽

Tertiary Care ◽

Retrospective Chart Review ◽

Primary Headache ◽

Final Diagnosis ◽

Initial Diagnosis ◽

Educational Strategies ◽

Diagnostic Uncertainty ◽

Peripheral Vertigo

Background:Previous studies describe significant rates of misdiagnosis of stroke, seizure and other neurological problems, but there are few studies examining diagnostic accuracy of all emergency referrals to a neurology service. This information could be useful in focusing the neurological education of physicians who assess and refer patients with neurological complaints in emergency departments.Methods:All neurological consultations in the emergency department at a tertiary-care teaching hospital were recorded for six months. The initial diagnosis of the requesting physician was recorded for each patient. This was compared to the initial diagnosis of the consulting neurologist and to the final diagnosis, as determined by retrospective chart review.Results:Over a six-month period, 493 neurological consultations were requested. The initial diagnosis of the requesting physician agreed with the final diagnosis in 60.4% (298/493) of cases, and disagreed or was uncertain in 35.7% of cases (19.1% and 16.6% respectively). In 3.9% of cases, the initial diagnosis of both the referring physician and the neurologist disagreed with the final diagnosis. Common misdiagnoses included neurocardiogenic syncope, peripheral vertigo, primary headache and psychogenic syndromes. Often, these were initially diagnosed as stroke or seizure.Conclusions:Our data indicate that misdiagnosis or diagnostic uncertainty occurred in over one-third of all neurological consultations in the emergency department setting. Benign neurological conditions, such as migraine, syncope and peripheral vertigo are frequently mislabeled as seizure or stroke. Educational strategies that emphasize emergent evaluation of these common conditions could improve diagnostic accuracy, and may result in better patient care.

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Prevalence of pneumonia in children under 12 years of age who undergo abdominal radiography in the emergency department

CJEM ◽

10.1017/s1481803500015293 ◽

2007 ◽

Vol 9 (05) ◽

pp. 347-351 ◽

Cited By ~ 6

Author(s):

Valérie Homier ◽

Colette Bellavance ◽

Marianne Xhignesse

Keyword(s):

Emergency Department ◽

Abdominal Pain ◽

Chest Radiograph ◽

Chest Radiography ◽

Acute Abdominal Pain ◽

Tertiary Care ◽

Abdominal Radiograph ◽

Upper Respiratory Tract ◽

Abdominal Radiography ◽

X Ray

ABSTRACT Objective: Pneumonia is a well-known cause of acute abdominal pain in children. However, the utility of chest radiography in this setting is controversial. We sought to determine the prevalence of pneumonia in children under 12 years of age who had abdominal pain and underwent abdominal radiography when visiting an emergency department (ED). We also aimed to describe the signs and symptoms of children diagnosed with pneumonia in this context. Methods: We conducted a retrospective analysis of electronic data from ED visits to a tertiary care centre by children 12 years of age and under who were seen between June 1, 2001, and June 30, 2003, and who underwent both an abdominal and a chest radiograph during the same visit, or an abdominal x-ray at a first visit as well as a chest x-ray in the 10 days following the initial visit. Results: Of 1584 visits studied, 30 cases of pneumonia were identified, for a prevalence of 1.89% (95% confidence interval 1.22%–1.56%). If chest radiography had been limited to children who presented with fever, cough and symptoms of an upper respiratory tract infection (URTI), the diagnosis of pneumonia would have been missed in only 2/1584 visits (0.13%). Conclusion: Children aged 12 years and under presenting to the ED with acute abdominal pain and in whom an abdominal radiograph is requested need only undergo a chest radiograph in the presence of cough, fever or other symptoms of a URTI.

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Status of Geriatric Patients with Abdominal Pain Presented To Emergency Department

Journal of Chitwan Medical College ◽

10.3126/jcmc.v9i2.24562 ◽

2019 ◽

Vol 9 (2) ◽

pp. 90-96

Author(s):

Daya Ram Lamsal ◽

Jeetendra Bhandari

Keyword(s):

Emergency Department ◽

Abdominal Pain ◽

Care Center ◽

Tertiary Care ◽

Medical Officer ◽

Common System ◽

Life Expectancy At Birth ◽

Chief Complaints ◽

Life Threatening ◽

The Common

Background: As the development of better health facilities with advanced tools for diagnosis and management our country is not away from global trend. Nepal’s life expectancy at birth is increasing at its pace, it has increased in about 30 years in last 4 decades. Among the various problem presenting to ED abdominal pain is one of the common complain elderly patients are greater risk of missing life-threatening causes during evaluation and investigation. The aim of the study wasEdit to identify the frequency, cause and outcome of patient presenting in Emergency department with abdominal pain. Methods: It is a retrospective study conducted in tertiary care center at Chitwan, Nepal during the period from 01/09/2017 to 30/08/2018. Electronic data entered by medical officer were retrieved and analyzed. Statistical analysis of the record was done using SPSS 16 software. Results: Elderly population who presented with chief complaints of abdominal pain was 1160 (21.79%). Among the patient presented with abdominal pain 605(52.2%) were male and 555(47.8%) were female. Mean age of patients was 71.72±8.50 years. Most common system involved was gastrointestinal and biliary problem 730(62.93%). Most common diagnosis was Urinary tract infection 269 (23.2%) among them, 487(41.98%) required hospital admission. Conclusions: Abdominal pain is one of the common presentations of elderly to emergency department. Disorders of Gastrointestinal and biliary system were among leading causes of emergency visit. Emergency physician should be tactful to identify life threatening conditions and emergency management.

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