3. Patient Case
• AS is a 33 y/o female with PMH of anxiety, asthma, PTSD, seizures,
lupus, and spinal arthritis presents to the ED with complaints of
nausea and vomiting that has been ongoing for 5 days. She was seen
3 days prior in the ED and has had an extensive history of ED visits for
nausea and vomiting.
• Patient height: 5 ft 6 in
• Patient weight: 63 kg
Initial Vital Signs:
BP 157/101
HR 65
RR 16
Temp 97.1
O2 Sat 98% on RA
7. What intervention has been linked to relieving
symptoms from cannabis hyperemesis syndrome?
A. Sleeping in
B. Hot shower/bath
C. Ice packs
D. Stretching
8. What intervention has been linked to relieving
symptoms from cannabis hyperemesis syndrome?
A. Sleeping in
B. Hot shower/bath
C. Ice packs
D. Stretching
11. Phases of CHS
1. Prodromal: Normal eating habits, continued
cannabis use
2. Hyperemetic: Nausea, vomiting, abdominal
pain, relief with hot showers/baths
3. Recovery: Restored eating habits, relative
wellness
16. Intravenous Haloperidol Versus Ondansetron for
Cannabis Hyperemesis Syndrome (HaVOC)
• Study published in 2021
• Randomized cannabis users with active emesis to either IV haloperidol
(0.05 mg/kg or 0.1 mg/kg, n = 13) or IV ondansetron (8 mg, n = 17)
• Primary outcome was reduction from baseline in abdominal pain and
nausea at 2 hours post-treatment, using the visual analog scale (VAS).
Ruberto AJ, Sivilotti MLA, Forrester S, Hall AK, Crawford FM, Day AG. Intravenous Haloperidol Versus Ondansetron for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial.
Annals of Emergency Medicine. 2021;77(6):613-619. doi:10.1016/j.annemergmed.2020.08.021
17. Intravenous Haloperidol Versus Ondansetron for
Cannabis Hyperemesis Syndrome (HaVOC)
• Haloperidol (at either dose) was superior to ondansetron (difference in 2.3 points on
VAS [Interval 0.6 - 4.0), p = 0.01).
• Haloperidol group had had less use of rescue antiemetics (31% vs. 59%).
• Haloperidol group had a shorter time to emergency department (ED) departure (3.1
hours vs. 5.6, p = 0.03).
• Safety: 2 return visits for acute dystonia, both in the higher-dose haloperidol group.
• Conclusion: Haloperidol was superior to ondansetron for the acute treatment of
cannabis-associated hyperemesis.
Ruberto AJ, Sivilotti MLA, Forrester S, Hall AK, Crawford FM, Day AG. Intravenous Haloperidol Versus Ondansetron for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial.
Annals of Emergency Medicine. 2021;77(6):613-619. doi:10.1016/j.annemergmed.2020.08.021
18. Patient Case Wrap-Up
• 6/26 visit: Given Pantoprazole, Ondansetron, IV fluids, and
Lorazepam. Discharged on Lansoprazole and Ondansetron.
• 6/27 visit: Given IV fluids, Promethazine, Pantoprazole, GI
Cocktail, Metoclopramide, Diphenhydramine, Potassium
Chloride, and Ondansetron. Admitted for observation.
• 6/30 visit: Given IV fluids, Pantoprazole, and Ondansetron.
Discharged on Ondansetron.
19. Patient Case Wrap-Up
• 4/15/21: Given fluids, Metoclopramide, Diphenhydramine,
Pantoprazole, fluids, Meclizine, Ondansetron, Promethazine, and GI
Cocktail. Discharged on Pantoprazole and Promethazine tablets.
• 4/17/21: Given fluids, Metoclopramide, Ketorolac, and
Diphenhydramine. Discharged on Promethazine suppositories.
• 4/19/21: Given fluids, Ondansetron, Diazepam, Ketorolac and
Metoclopramide. Admitted to inpatient.
• 5/15/22 visit: Given IV fluids, Ketorolac, Ondansetron, Haloperidol,
Diphenhydramine, and Hydroxyzine. Discharged on Ondansetron.
21. Case Report
Jones JL, Abernathy KE. Successful Treatment of Suspected Cannabinoid Hyperemesis Syndrome Using Haloperidol in the Outpatient Setting. Case Rep Psychiatry. 2016;2016:3614053.
doi:10.1155/2016/3614053
23. References
• Venkatesan T, Levinthal DJ, Tarbell SE, et al. Guidelines on management of cyclic vomiting syndrome in adults by the
American Neurogastroenterology and Motility Society and the Cyclic Vomiting Syndrome Association.
Neurogastroenterology & Motility. 2019;31(S2):e13604. doi:10.1111/nmo.13604
• Ruberto AJ, Sivilotti MLA, Forrester S, Hall AK, Crawford FM, Day AG. Intravenous Haloperidol Versus Ondansetron
for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial. Annals of Emergency Medicine.
2021;77(6):613-619. doi:10.1016/j.annemergmed.2020.08.021
• Ruberto AJ, Sivilotti MLA, Forrester S, Hall AK, Crawford FM, Day AG. Intravenous Haloperidol Versus Ondansetron
for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial. Annals of Emergency Medicine.
2021;77(6):613-619. doi:10.1016/j.annemergmed.2020.08.021
• Rome IV Criteria. Rome Foundation. Accessed July 5, 2022. https://theromefoundation.org/rome-iv/rome-iv-
criteria/
• Rome IV Diagnostic Criteria for Cannabinoid Hyperemesis Syndrome (CHS). MDCalc. Accessed July 5, 2022.
https://www.mdcalc.com/calc/10298/rome-iv-diagnostic-criteria-cannabinoid-hyperemesis-syndrome-chs
• Jones JL, Abernathy KE. Successful Treatment of Suspected Cannabinoid Hyperemesis Syndrome Using Haloperidol
in the Outpatient Setting. Case Rep Psychiatry. 2016;2016:3614053. doi:10.1155/2016/3614053
• The Prevalence of Cannabinoid Hyperemesis Syndrome Among Regular Marijuana Smokers in an Urban Public
Hospital - Habboushe - 2018 - Basic & Clinical Pharmacology & Toxicology - Wiley Online Library. Accessed
July 5, 2022. https://onlinelibrary.wiley.com/doi/10.1111/bcpt.12962
25. Patient Case
Wrap-Up
• 6/26 visit: Given Pantoprazole,
Ondansetron, IV fluids, and Lorazepam.
Discharged on Lansoprazole and
Ondansetron.
• 6/27 visit: Given IV fluids, Promethazine,
Pantoprazole, GI Cocktail, Metoclopramide,
Diphenhydramine, Potassium Chloride, and
Ondansetron. Admitted for observation.
• 6/30 visit: Given IV fluids, Pantoprazole,
and Ondansetron. Discharged on
Ondansetron.
Physical exam: awake, alert, in no distress, CHEST: Normal chest wall appearance and motion, CARDIAC: regular rate and rhythm, RESPIRATORY: clear to auscultate, no crackles or wheezing, ABDOMEN/GI: Soft, tender, normal bowel sounds. No distention, guarding, rebound, or tenderness.
The present hypothesis is that CHS may result from chronic overstimulation of endocannabinoid receptors, leading to derangements in the body’s intrinsic control of nausea and vomiting.
Possible mechanisms of cannabinoid hyperemesis include toxicity resulting from marijuana's long half-life, its lipophilic properties, its ability to delay gastric emptying, its dysregulation of thermoregulatory and autonomic equilibrium through its effect on the limbic system, and the binding of cannabinoids to cannabinoid type 1 (CB1) receptors in the brain
A crucial factor in the genesis of CHS is the composition of cannabis. Since the 1990s, there has been a progressive change in the composition of the plant, with increases in the tetrahydrocannabinol (THC) and a reduction of cannabidiol (CBD).
The present hypothesis is that CHS may result from chronic overstimulation of endocannabinoid receptors, leading to derangements in the body’s intrinsic control of nausea and vomiting One proposed mechanism is that increasing body temperature can potentially reverse the chronic hypothalamic CB receptor stimulation.
May also play a role in the potential vanilloid-1 nociceptor system, which becomes activated by both acidic pH and high temperatures. It uses sodium and calcium channels to regulate the release of substance P, a mediator involved in the perception of pain, and hence may offset the focus of N/V.
Prodromal: months to years
Hyperemetic: 24 to 48 hours
Recovery: days to months
You want a thorough evaluation to exclude other etiologies for the symptoms (such as bowel perforation, cholecystitis, pancreatitis, etc.) or potential complications of excessive vomiting (ex: loss of electrolytes)
Currently diagnosed with Rome IV criteria under Gastroduodenal disorders. Can also use MDCalc.
The pathological phenomenon of “hot water bathing” was a supporting criterion even though this behavior can also be seen in ~50% of patients with CVS who do not use cannabis.
They may categorize her as presumptive CHS or could make the diagnosis of cyclic vomiting syndrome
Can also consider PPI if having pain from vomiting (midepigastric or dyspeptic quality pain)
- Antiemetics, sedating agents, fluids, and analgesics used for supportive care also treatment for CVS
i.e. Ondansetron, Promethazine, Metoclopramide
Metoclopramide, a commonly used antiemetic, acts as an antagonist to the same chemoreceptor trigger zone in the brainstem opposing the vomiting reflex. It also increases grastric motility, thereby further decreasing the emetic response
Benzos: proposed MOA is that it decreases activation of Cannabinoid Type 1 Receptor (CB1) in the frontal cortex, has a sedative and hypnotic effect and reduces the anticipation of nausea and vomiting.
Fluids: restore any dehydration and electrolyte abnormalities from cyclic vomiting
Capsaicin: The aforementioned transient receptor potential vanilloid-1 nociceptor system becomes activated by both acidic pH and high temperatures, which use sodium and calcium channels to regulate the release of substance P, a mediator involved in the perception of pain, and hence may undergo modulation through the use of topical capsaicin as well as exposure to hot water.
Haloperidol: refractory to all prior interventions and persist with moderate to severe abdominal pain and vomiting
Study took place at 2 academic center’s EDs in Ontario, Canada
Study took place at 2 academic center’s EDs in Ontario, Canada
Discharge medications to abort acute episodes are a logical management strategy and may be a safe option to reduce recurrent ED visits in some patients.
Oral haloperidol for CHS is being studied. One case report of an 18 year old female with one-year history of refractory nausea, vomiting, and abdominal pain after prolonged use of cannabis (2-3 x per day)
