In the last decade, the medical community has seen extensive innovation into designer drugs and synthetic tetrahydrocannabinol (THC) derivatives. As marijuana laws change across the United States allowing medicinal and recreational usage to surge, new forms of high-potency synthetic and natural marijuana products are entering into common usage.1 With medicinal use and legalization, trends are already indicating increased use and are projected to continue increasing.2 Awareness among the medical community of new drug forms has often lagged behind this rapidly expanding arena.3 As the frontlines of the medical system, it’s imperative EMS personnel stay abreast of new drug developments, especially those that affect prehospital care.
The synthesis of butane hash oil (BHO) is a particularly dangerous drug-related activity that can produce explosions and structure fires. This latest trend is a new twist on an old form of marijuana and is known as “wax,” “ear wax,” “shatter,” “honey oil” or “butter” because of its yellow color and soft, solid texture. (See Figure 1). This high-potency product is made by extracting cannabinoids from marijuana plants with butane gas, then evaporating the butane to leave behind concentrated cannabinoids with up to 85% THC concentration.4 The following cases involve patients with a wide array of complications of both using and producing BHO.
Figure 1: Pliable consistency and soft texture of BHO. Figure Wikimedia Commons/Coaster420
Prehospital assessment: A 24-year-old male was brought in by paramedics after jumping from a moving car while he was driving on a highway at approximately 65 mph. There was no collision with other cars in the incident. Witnesses reported the patient tumbling on the asphalt, then scrambling to the median where he was found by paramedics sitting against the center divider of the highway. Medics noted it was a single vehicle accident without obvious cause. Upon paramedic arrival, he was alert and oriented, and complaining of diffuse abdominal and extremity pain. Mild bleeding was noted from widespread abrasions.
Upon further questioning, he acknowledged smoking a “dab hit of wax,” which he described as a full inhalation of smoke, in a medical marijuana clinic prior to getting into his car. He used BHO approximately four times in the past, but said this time he “had a bad trip” with severe paranoia. While driving his car approximately 15 minutes after the inhalation, he believed that “the devil and God were fighting for [his] soul, and the devil started squeezing [his] lungs and [he] couldn’t get enough oxygen, so [he] had to jump out of the car.”
Prior to arrival to the ED, his blood pressure (BP) was 135/84, heart rate was 119, respiratory rate was 18, oxygen saturation was 95% on room air and temperature was 36.4 degrees C. EMS providers placed the patient in a C-collar and on a backboard, and established an IV en route to a Level 1 trauma center.
Hospital course: The primary survey was significant for diffuse road rash to bilateral flanks and bilateral upper and lower extremities, which were consistent with his reported mechanism of injury. A focused assessment with sonography in trauma (FAST) was negative. Laboratory evaluation was unremarkable, including a negative urine toxicology screen that doesn’t include THC derivatives. X-rays of his chest and pelvis and CT scans of his head, cervical spine, chest, abdomen and pelvis showed no evidence of acute traumatic injuries. Aside from marijuana wax, he denied current alcohol, tobacco or other illicit drug use. He indicated no previous medical or psychiatric history. He was seen by the psychiatric consult service and the diagnosis given was psychotic episode secondary to substance use. The patient wasn’t placed on a psychiatric hold and was discharged the next day after wound care, tetanus update and complete resolution of psychosis.
Prehospital assessment: A 28-year-old male and patient 3 were both found by EMS personnel after an explosion at a private residence. The patient was lying on the ground outside of an en-flamed house with extensive burns. Police on the scene were able to confirm that the cause of the fire was a butane explosion during the production of marijuana wax according to paraphernalia found at the scene and confirmed by report of the two victims involved in the fire. Initial vitals were BP of 143/102, heart rate of 107, respiratory rate of 28, and oxygen saturation of 99% on room air. The initial examination showed approximately 80% total body surface area (TBSA) burns, including facial burns with sloughed skin and burned facial and nasal hair. (See Figure 2.) His initial Glasgow Coma Scale was 4-6-1. Paramedic providers transported him to the nearest burn center. His airway was deemed stable for the 10-minute transport. He was placed in a C-collar, put on a backboard, and an IV was started with 600 cc normal saline given en route.
Figure 2: Areas of second- and third-degree burns to patient 2. Figure courtesy LA County + USC Medical Center
Hospital course: Upon arrival to the ED, the patient underwent successful rapid sequence endotracheal intubation and had bilateral femoral sheath introducer catheters placed to facilitate the initial resuscitation. A bladder temperature of 33.9 degrees C was measured. The patient received resuscitative IV fluids using the Parkland formula. The FAST assessment was negative. The patient received a CT scan of the head, cervical spine, chest, abdomen and pelvis to evaluate for associated injuries. CT head and cervical spine were unremarkable, while the CT chest/abdomen/pelvis showed early inhalational lung injury, as well as mucosal enhancement of the small bowel with wall thickening thought to represent blast injury. (See Figure 3 and Table 1.)
Figure 3: Abdominal CT demonstrating bowel wall edema caused by primary blast injury. Figure courtesy LA County + USC Medical Center
Table 1: Blast injury5
After returning from the radiology suite, the patient developed bradycardia with a heart rate in the 30s, which responded appropriately to atropine 0.5 mg and bicarbonate 1 amp. After transfer to the burn ICU, the patient received escharotomies to the left and right legs, chest and abdomen, as well as multiple skin grafts. Blast injury to his lungs required prolonged ventilator care. He was eventually discharged over six months later.
Prehospital assessment: A 21-year-old male, who was involved in the same explosion as patient 2, was found by paramedics collapsed on the street several blocks from the fire after a failed attempt to flee the scene. The initial vitals were BP of 100/82, heart rate of 98, respiratory rate of 34, oxygen saturation of 100% on room air, and temperature of 36.6 degrees C. The initial examination showed approximately 45% TBSA burns including facial burns with sloughed skin and burned facial and nasal hair. (See Figure 4.) Paramedics placed the patient in a C-collar, on a backboard and started an IV with normal saline 400 cc given during transit. The patient was brought to a Level 1 trauma and burn center and his airway was deemed stable for the 10-minute transport.
Figure 4: Areas of second- and third-degree burns to patient 3. Figure courtesy LA County + USC Medical Center
Hospital course: A FAST exam was negative. Though his initial GCS was 15, he underwent emergent rapid sequence endotracheal intubation given the predicted adverse clinical course. A left subclavian sheath introducer catheter was placed and the patient received resuscitative IV fluids using the Parkland formula. Initial CT scans of the head, cervical spine, chest, abdomen and pelvis were unremarkable. While in the burn ICU, the patient received multiple skin debridements and grafts. The patient was subsequently extubated and discharged after 31 days in the hospital.
Prehospital assessment: A 25-year-old male was found by paramedics and fire personnel after an explosion while he was “cooking marijuana wax,” per his report. He was transported by helicopter to the nearest burn center. His initial vital signs were BP of 126/77, heart rate of 96, respiratory rate of 16, oxygen saturation of 100% on 6 liters by nasal cannula, and temperature of 36.6 degrees C.
The initial examination showed the patient was alert and speaking in full sentences, though he had singed eyebrows, eyelashes, nasal hair and moustache hair. In addition, he was complaining of subjective hoarseness of voice. The patient was placed in a C-collar and on a backboard. The patient received IV 1 L normal saline en route to the closest Level 1 trauma and burn center. His airway was deemed stable for the 25-minute helicopter transport.
Hospital course: During the initial primary survey the patient produced significant carbonaceous sputum and was emergently intubated using rapid sequence technique. Initial exam revealed 28% TBSA partial thickness burns with blistering to the bilateral upper and lower extremities and to the back. (See Figure 5). A CT scan of the chest showed subcutaneous emphysema, a tiny right pneumothorax, pneumomediastinum, and interstitial emphysema compatible with barotraumas due to blast injury. (See Figure 6.) The patient was extubated and discharged after 15 days in the hospital.
Figure 5: Areas of second- and third-degree burns to patient 4. Figure courtesy LA County + USC Medical Center
Figure 6: Chest CT of patient 4.
Chest CT showing diffuse emphysematous changes within the mediastinum, subcutaneous and pleural spaces due to primary blast injury. Figure courtesy LA County + USC Medical Center
Incidents involving BHO extraction are on the rise throughout California. On April 8, 2014, the Los Angeles County Hazmat Division received three separate calls related to scene evaluation.6 Many of the fires associated with BHO involve an explosion creating unique scene dangers and structure instability. Three of the above cases involved explosive fire events with blast injury patterns identified in at least two victims. One news report identified three BHO explosions in a twomonth period in Southern California.7 One explosion damaged a hotel near San Diego Sea World, one occurred in West Hollywood shattering windows and blowing out wall supports, and another occurred in northeast Los Angeles. Still another explosion injured three BHO extractors in Mount Vernon, Calif., on August 16, 2014.
The U.S. Fire Administration (USFA) noted that these BHO-related fires and explosions are increasing. News reports indicate similar events in Colorado, Oregon and Hawaii. In an Infogram alert from Feb. 7, 2013, the USFA noted the explosions might resemble pipe bombs or methamphetamine lab explosions. Some of the explosions involve freezers or refrigerators used to minimize flammable vapors. On the scene there are often signs that may tip off EMS providers to the nature of the fire. Butane canisters, Pyrex dishes, polyvinyl chloride (PVC) pipe, and other solvents may be found, increasing suspicion the fire is BHO-related. The badly burned victim is often in need of medical care and transport to a burn center is the most obvious indicator via their history.
Both wax usage and synthesis can produce injuries of high complexity. These four cases represent paranoia, psychosis, multisystem blunt trauma, complex burns, inhalational injuries and blast injury patterns. A search of the medical literature pertaining to wax yielded only one recently published article describing survey data of BHO’s effects from the user perspective and outlining BHO’s increasing prevalence.10 The lay press has numerous articles corroborating its emerging popularity because of the increased potency and subsequent intensity of the high from this extract.11–12 This was outlined in a recent Toxicology column in Emergency Medicine News.13
The manufacturing of this oil is similar to other hash oil except instead of using sieves or ice baths to extract THC concentrate from the plant, BHO is made by using butane flushed over the plant material. This process is referred to as “blasting,” which the butane method supposedly does with higher efficacy. The butane is then evaporated off using a heat source, called “purging,” and then dried. The resulting oil contains a high concentration of THC by weight, up to 85%. This process creates potential for both fires and explosions.
Production and consumption of this highly concentrated form of marijuana can lead to multiple types of injuries pertinent to prehospital providers.14,15 Users refer to smoking this product as “dabbing.” It can be smoked using an electronic vaporizer pen or a specialized type of bong called an “oil rig” using a blowtorch to heat a metal piece, called a nail, where the wax is placed with a tool to be vaporized for inhalation. The latter apparatus poses a risk of local burns or fires. (See Figure 7.) More importantly, when making BHO, the purging of butane with a heat source can lead to larger scale fires if the butane is ignited, as was the situation in patients 2, 3 and 4. This is especially likely with homemade extraction techniques, where unsafe heating systems are used, leading to butane combustion. These can be similar to methamphetamine lab explosions and require similar precautions for scene safety. It’s also important to disposition these patients appropriately with the potential for simultaneous traumatic and burn-related injuries.
Figure 7: ‘Oil rig’
Blowtorch heating the nail of an “oil rig” used to vaporize BHO for inhalation. Photo courtesy The 420 Times
The connection between marijuana and psychosis is controversial but there’s evidence of a link.16,17 It’s difficult to decipher whether the root cause of a psychotic episode is functional or drug-induced in these situations, as in the case of patient 1. Many questions are raised about the effects of this new cannabis concentrate and possible potentiation of psychosis. There’s concern among habitual users that BHO is more dangerous than other forms of marijuana, and speculation about the increased potency leading to psychiatric disease.8 For now, the correlation should be noted by EMS personnel.
High-potency marijuana wax smoked via dabbing is a newly encountered phenomenon with relevance to prehospital care providers and emergency physicians. The extract is only recently described in current peer-reviewed literature. The drug may produce paranoia and psychosis and mimic psychiatric problems. The synthetic process for this drug poses a risk for both fire and explosions creating burns and blast injuries. These four cases were encountered in a single ED in Los Angeles in a three-week period, suggesting this could be the tip of an emerging public health problem. All four of these patients were complex cases requiring advanced imaging and ICU care. Emergency personnel need to appreciate this new trend and the implications for prehospital care, disposition and ED treatment of these patients.
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