Cannabis and Psychosis

Californians voted to legalize recreational pot in 2016. Three years later, emergency room visits for cannabis-induced psychosis went up 54% across the state, from 682 to 1,053, according to state hospital data. For people who already have a psychotic disorder, cannabis makes things worse — leading to more ER visits, more hospitalizations, and more legal troubles, said Dr. Deepak Cyril D’Souza, a psychiatry professor at Yale University School of Medicine who also serves on the physicians’ advisory board for Connecticut’s medical marijuana program.

California May Require Labels on Pot Products to Warn of Mental Health Risks — https://khn.org/news/article/california-marijuana-warning-labels/

Listen to the article above here: https://www.npr.org/sections/health-shots/2022/06/17/1105494283/california-pot-warning-labels

Recreational cannabis use is linked to a heightened risk of emergency care and hospital admission for any cause, finds research published in the open access journal BMJ Open Respiratory Research.

Cannabis use linked to heightened emergency care and hospital admission risks — https://medicalxpress.com/news/2022-06-cannabis-linked-heightened-emergency-hospital.html

Cannabinoid Hyperemesis Syndrome

It’s not entirely clear how cannabis hyperemesis syndrome occurs though there are several theories. One is that since cannabinoids have long-half lives and are lipid soluble, they accumulate in the brain and over time cause symptoms, particularly in young people who may have genetic variations in enzymes which lead to further accumulation. Another theory is that there is a thermoregulatory and autonomic imbalance in the limbic system caused by chronic use. Other suggestions are that with long-term consumption cannabis becomes a receptor antagonist, or that they become down-regulated or de-sensitised over time. This reverses the antiemetic effect of cannabis. It seems that chronic over-stimulation of receptors leads to dysregulation of the body’s control of nausea and vomiting, leading to CHS.

Owen Hibberd . What you need to know about Cannabinoid Hyperemesis Syndrome, Don’t Forget the Bubbles, 2022. Available at: https://doi.org/10.31440/DFTB.48627

I am so glad I never inhaled.

The Dog Doctor Will See You Now

Clinically significant changes in pain as well as significant changes in anxiety, depression and well-being were observed in the therapy dog intervention compared to control. The findings of this novel study contribute important knowledge towards the potential value of ED therapy dogs to affect patients’ experience of pain, and related measures of anxiety, depression and well-being….visiting therapy dog teams had a positive, though small, impact on patient pain and related measures of anxiety, depression and well-being.

Outcomes of a controlled trial with visiting therapy dog teams on pain in adults in an emergency department — https://doi.org/10.1371/journal.pone.0262599

Woof.

Transient Ischemic Attack (TIA) – a Primer

The incidence of TIA in the United States is estimated to be 200,000-500,000 per year, with a prevalence of 5 million individuals, but is likely underreported.2 Stroke is preceded by TIA in 12-30% of patients and is the 5th leading cause of death in the US, contributing significantly to long term disability.2,3 Strokes occur more commonly in men than women, but women experience more severe morbidity.2,3 Stroke prevalence increases with age and occurs more frequently in black and Hispanic populations.3 It should also be noted that 90% of strokes worldwide occur in the setting of potentially modifiable risk factors which presents an incredible opportunity for early intervention, especially following TIA.2

TIA: Emergency Department Evaluation and Disposition — http://www.emdocs.net/tia-emergency-department-evaluation-and-disposition/?utm_source=feedly&utm_medium=rss&utm_campaign=tia-emergency-department-evaluation-and-disposition

Rocky Mountain Spotted Fever (RMSF)

RMSF is the most common fatal rickettsial illness in the United States.

Overall hospitalization rates are noted be at 23.4% based on aggregated reviews of case reports (Openshaw 2010.

Case fatality rate is estimated to be 5-10% overall (Biggs 2016). If treatment is delayed, case-fatality rates of 40-50% have been described for patients treated on day 8 or 9 of their illness.

Case fatality rate is highest in those over the age of 70 (Amsden 2005).

Without treatment, the case fatality rate is over 25% (Lacz 2006).

Citation: Muhammad Durrani, “Emerging Tick-Borne Illnesses: Not Just Lyme Disease Part 4 RMSF”, REBEL EM blog, November 5, 2020. Available at: https://rebelem.com/emerging-tick-borne-illnesses-not-just-lyme-disease-part-4-rmsf/.

The CFR for untreated RMSF surprised me.

And yet another reason besides bears to stay out of the woods.

Remind me to tell some of my favorite tick stories when we can all gather unmasked to enjoy some food and drink.

Benzodiazepines Implicated in High Rate of ED Visits Across US

Seven out of eight emergency department (ED) visits attributed to adverse events from benzodiazepines involve self-harm or nonmedical use of these drugs, and more than 80% involve concurrent use of alcohol, illicit drugs, or other substances, new research shows.

Although benzodiazepines are typically not problematic in terms of acute overdoses when used alone, patients often don’t take them as prescribed or use them with other substances in a self-harm attempt, author Daniel S. Budnitz, MD, MPH, director of the Medication Safety Program, Centers for Disease Control and Prevention (CDC), told Medscape Medical News.

“Clinicians need to be aware of what other substances patients might be taking when they’re being prescribed a benzodiazepine,” Budnitz added.

The study was published online February 19 in the American Journal of Preventive Medicine.

Benzodiazepines Implicated in High Rate of ED Visits Across US – Medscape – Feb 25, 2020 – https://www.medscape.com/viewarticle/925686#vp_1

Ten Commandments of Emergency Medicine Revisited

#2 Remember naloxone, glucose, and thiamine (NGT)
Original: Consider or give naloxone, glucose and thiamine
The number of patients presenting with opioid intoxication is growing, and the gentle reversal of patients without severe respiratory depression with naloxone is in the art of medicine – consider starting with 0.4mg and titrate to effect.

In contrast to empiric administration of glucose in the altered or ill patient, rapid assessment of glucose level with point-of-care testing is recommended.

Thiamine deficiency may be less prevalent than previously thought in intoxicated patients, but we now know that giving 100mg of IV thiamine can benefit other malnourished patients, including those with calorie-malnourishment from cancer, gastric bypass, hyperemesis gravidarum, and eating disorders. Personally, I use the ‘T’ of ‘NGT’ to remind myself not to miss alcohol withdrawal.

Ten Commandments of Emergency Medicine Revisitedhttps://journalfeed.org/article-a-day/2021/ten-commandments-of-em-revisited

Why does this matter? I hear you thinking we underwrite life insurance, we’re not doctors. So true. But if we think like doctors we will get better at what we do by recognizing the subtleties buried within the medical charts we read. Here’s what my eyes/brain picked up.

The bold in the excerpt above are mine to illustrate how the mind of a mortality risk expert works. In Emergency Department records pay attention to the initial treatments provided which in some cases hints to a serious condition impacting mortality. Naloxone and opioids are obvious. But would you have associated the administration of IV thiamine to malnutrition or alcohol withdrawal? I thought so.

So read and research widely. You’ll always find little jewels to improve your skills and to impress your friends with. Or in my case to make Dr. Lee think his old man knows more than he actually does.