II. Pathophysiology
- Associated with chronic Marijuana use
- Proposed mechanisms
- Cerebral fat deposition of lipophilic Marijuana metabolites with frequent Marijuana use
- THC binding to vanilloid receptors in the Hypothalamus (transient receptor potential vanilloid receptor, TRPV1)
- Low THC concentrations and warmer Temperatures (>109.4 F or 43 C) are Anti-emetic
- High THC concentrations are pro-emetic
III. Diagnosis
- Essential criteria
- Chronic Marijuana use
- Major criteria
- Supportive criteria
- Age under 50 years
- Weight loss over 5 kg
- Symptoms predominant in morning
- Normal bowel habits
- Negative diagnostic evaluation
IV. Management
- Home
- Marijuana cessation
- Symptomatic relief with hot showers or bath
- Emergency Department
- Antiemetics (e.g. Ondansetron, Prochlorperazine, Promethazine, Metoclopramide)
- Typically less effective in canabinoid hyperemesis
- Capsaicin cream (0.075%)
- May work on vanilloid receptors in Hypothalamus (similar to the action of a hot shower)
- Emergency Department Protocol
- Apply 0.075% Capsaicin cream as a thin film every 4 hours until symptoms resolve
- Apply cream to 15 x 25 cm or palm sized area periumbilical area using a gloved finger
- Peak effect in 20-30 minutes and lasts 3 hours
- References
- LoVecchio (2022) Crit Dec Emerg Med 36(6): 32
- Dezieck (2017) Clin Toxicol 55(8): 908-13 +PMID:28494183 [PubMed]
- Haloperidol
- Haloperidol 2.5 mg IV or IM
- Some studies have used doses as high as 0.05 to 1 mg/kg IV (higher than typical dosing)
- Jones (2016) Case Rep Psychiatry +PMID: 27597918 [PubMed]
- Ruberto (2021) Ann Emerg Med 77(6):613-619 +PMID:33160719 [PubMed]
- Haloperidol 2.5 mg IV or IM
- Inapsine (Droperidol)
- Dosing: 0.625 mg to 1.25 mg IV
- Lee (2019) Clin Toxicol 57(9): 773-7 [PubMed]
- Antiemetics (e.g. Ondansetron, Prochlorperazine, Promethazine, Metoclopramide)
V. References
- Orman and Zodda in Herbert (2018) EM:Rap 18(2): 10
- Oxentenko (2011) Mayo Internal Medicine Review