The smell of emesis can be detected as you and your partner enter the apartment. The patient’s sister leads you to a bathroom at the back of the house where you hear a shower running coupled with the sounds of someone vomiting. Upon entering you see a male in his late 20s, dripping wet, with his head in the toilet, vomiting. The steam from the shower makes it difficult to see much else, and the room is hot.
You announce your arrival and the patient slowly looks up at you. Your partner turns off the shower and you begin your assessment.
The patient is awake and has a strong, rapid pulse. His skin is hot to the touch, most likely from the hot shower. He tells you he hasn’t sustained any physical trauma and has been throwing up “nonstop” for the past two days.
You and your partner help cover him with a towel and assist him to a sitting position on the floor. The patient tells you this is the second time in the last several months he’s experienced a sudden onset of uncontrollable vomiting like this and, like last time, he’s unable to keep any food down and has lost his appetite. He denies symptoms associated with illness such as fever, sore throat, runny nose or body ache, and hasn’t experienced diarrhea with the abdominal upset. Last time the nausea and vomiting went away after about three days.
This episode occurred while he’s staying with his sister and she’s the one who called 9-1-1. He denies taking any prescription medications, herbal remedies or illicit substances. He says he drinks occasionally, but denies alcohol within the past week and says he uses marijuana, both smoked and edibles. He tried smoking marijuana with his onset of nausea hoping it would relieve his symptom but it didn’t help.
His pulse is 118 and his blood pressure is 108/72. He tells you he becomes dizzy when he stands. Your physical exam reveals a healthy young male with nausea and vomiting. When asked about the shower, he tells you that a hot shower or hot bath is the only thing that seems to relieve his symptoms.
You help him to your stretcher, covering him to keep him warm. His sister gives you some clothes to take with him to the hospital and you begin transport. You administer Zofran (ondansetron), which offers your patient no relief. He’s transferred to the ED staff without change.
Treating a patient with nausea and vomiting can be a challenge. It’s sometimes difficult to make the patient comfortable and there are many possible causes for nausea and vomiting that must be considered, including head injuries, pregnancy, cardiac problems and gastrointestinal illnesses. In this case, the patient was diagnosed with cannabinoid hyperemesis syndrome (CHS).
Cannabis, more commonly known as marijuana, is, according to the World Health Organization, the world’s most widely cultivated, trafficked and abused illicit substance.1
On the federal level, marijuana is listed as a Schedule I drug, meaning it has no medicinal value and is addictive with a high abuse potential, making it illegal to possess. Several states, including Colorado, Oregon, Alaska and Washington, have legalized marijuana for recreational use and several other states have laws allowing medicinal marijuana use.
The common effects of marijuana are alteration of psychomotor behavior, appetite stimulation, mild analgesia and anti-nausea effects. There can also be loss of short-term memory.
The exact cause of CHS remains unknown. It typically begins slowly after frequent marijuana use with the sensation of nausea, commonly upon waking. Patients regularly use more marijuana to treat the nausea. Continued marijuana use, however, propagates the symptoms and patients will develop sudden onsets of intense nausea and vomiting commonly with mild, diffuse abdominal pain.
The learned activity to reduce the nausea and abdominal pain is to take hot showers or baths. In some patients the bathing becomes compulsive. As much as the onset of CHS is unexplained, the effects of the hot bathing are also unexplained. All symptoms resolve with the cessation of marijuana use but typically return if patients begin using again.
Prehospital treatment for CHS is mostly supportive. Always consider life-threatening conditions and treat as appropriate.
Patients who’ve been vomiting for several days can present with dehydration and may benefit from fluid resuscitation. Anti-nausea medications such as Zofran may have little effect on the symptoms but can be tried. Based on local protocols, pain medications are a consideration if the abdominal pain is severe but aren’t commonly needed. Also consider the possibility of other chemicals being used by the patient, which may potentially be pain medications.
With the push to legalize marijuana for recreational use, the potential for increased use exists. Alternative forms of marijuana consumption such as edibles make marijuana use less obvious.
The actual incidence of CHS is unknown, largely due to it being unrecognized by healthcare workers. However, it’s likely EMS will be encountering patients with CHS more frequently.
1. World Health Organization. (2015.) Cannabis. Retrieved Aug. 18, 2015, from www.who.int/substance_abuse/facts/cannabis/en/.