Can you name some of your favorite types of patients in the Emergency Department? Weak and dizzy? Syncope? Low back pain? How about gastroparesis or cyclic vomiting syndromes?
Well, good news – if drug-induced vomiting is on your list of rewarding patient encounters, then this wave of states with newly legalized marijuana is just for you.
This is a small review of two urban, academic Emergency Departments in Colorado, retrospectively analyzing their diagnoses for encounters involving nausea & vomiting. The breakpoint in their analysis was the legalization of recreational marijuana in 2009. Through, frankly, a great number of assumptions involving documentation, drug screens, and other chart review calisthenics, the authors distilled out the patients with multiple ED visits for vomiting associated with drug abuse – clinically, the cyclic vomiting syndrome. And, if you accept the limitations of their review: the number of visits for cyclic vomiting to their EDs has doubled since the introduction of legalized marijuana.
Hooray.
Interestingly, there is also a small exploratory analysis included in the paper regarding the antiemetic of choice. They note promethazine use, despite the small sample, was significantly associated with needing admission – with an OR of 5.06 (95% CI 2.01 to 13.63). Whether this represents unmeasured cofounders or a real effect is uncertain. Anecdotally, with some evidence to support the practice, I have good experiences with droperidol and haloperidol in these sorts of patients.
“Cyclic Vomiting Presentations Following Marijuana Liberalization in Colorado”
http://www.ncbi.nlm.nih.gov/pubmed/25903855
I will have to try haldol the next time I have these patients. That and telling them to go home, take a hot shower, and STOP SMOKING MARIJUANA!!!
Do you see patients presenting with "I'm dehydrated" as their chief complaint , and who yet do tolerate fluid intake ? I've seen a few. Amazing.
For vomiting we use mostly metoclopramide , another neuroleptic (I can prove that with some typical side effects. Less sedative than "overt" neuroloptics.
IV haloperidol (let alone droperidol) are severely frowned upon nowadays. So do you give it IV or I , after an EKG ?
I've had one facility crack down on IV haloperidol; interestingly, they never had issues with IV droperidol when it was in stock. Other facilities let me administer it IV without an EKG or specific monitoring.
Ive started doing 10mg IM haldol on arrival for cyclic vomiters (if I cant do 2.5 – 5mg IV) with good results. I give them warm blankets and toradol for pain control, and probably about 85% of the time I can discharge them.
You know, a slug of reglan 10mg, benadryl 50mg, and ativan 1mg IV with a liter or two of fluids and they are out of the ER in about 45-75min.