Death after consuming a marijuana edible

Screen Shot 2015-07-23 at 2.01.10 PM4 out of 5 stars

Death Following Ingestion of an Edible Marijuana Product — Colorado, March 2014. MMWR 2015 July 24;64:771-772.

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This report describes the investigation by the Colorado Department of Public Health and Environment (CDPHE) into a well-publicized fatality that occurred shortly after recreational marijuana became available in that state.

In March 2014, a 19-year-old man ingested one piece of a marijuana cookie purchased by his 23-year-old friend. (Note: at that time as well as now, the legal age for using marijuana in Colorado was 21.) When he felt no effects after 30-60 minutes, he ingested the remainder of the cookie:

“During the next 2 hours, he reportedly exhibited erratic speech and hostile behaviors. Approximately 3.5 hours after initial ingestion, and 2.5 hours after consuming the remainder of the cookie, he jumped off a fourth floor balcony and died from trauma.”

The CDPHE investigation of this case provides some interesting details that hadn’t been reported previously in media coverage:

  • The deceased teenager had no previous history of drug or alcohol abuse, or mental illness.
  • The cookie content was listed on the label as “65 mg THC/6.5 servings.” The victim initially followed instructions and ate one-sixth of a cookie, but ingested the rest of the total 65 mg shortly thereafter.
  • The victim’s THC level at autopsy (central blood) was 7.2 ng/ml.

There are several things to note in this report. The THC level of 7.2 ng/ml at autopsy (performed 29 hours after death) was surprisingly low — the (rather arbitrary) legal limit for driving in Colorado is 5.0 ng/ml. Since THC undergoes post-mortem redistribution, the level at the time of death might have been even lower than the legal limit. This finding shows that blood THC levels are not good indicators of clinical effect. In addition, when ingested, THC undergoes the hepatic first-pass effect, producing the active metabolite 11-OH-THC, which may be more potent and longer-lasting than THC itself. Because of this — and because when marijuana is ingested it has a prolonged time to peak effect (1-2 hours) and longer duration than when smoked — the effects of marijuana edibles may be substantially different from those experienced after smoking or vaping.

I covered these issues in my Emergency Medicine News column “Four Things Maureen Dowd Should Have Known About Cannabis Before Going to Denver.” To read the column, click here.

App in Pills – Luglio 2015: EGA Pro

Benvenuti al secondo appuntamento di App in Pills, il “bimestrale” (salvo problemini… tecnici dello scorso mese!) dedicato alle applicazioni per dispositivi mobili nel campo della medicina d’urgenza… e non solo! Come promesso cercherò di variare un po’ tra i sistemi operativi disponibili. Infatti oggi vi parlerò di EGA Pro, un’applicazione Android, creata da Stefano Ramilli, medico […]

The post App in Pills – Luglio 2015: EGA Pro appeared first on EM Pills.

@WUSTL_EM #EMConf: #FOAMed Supplement No. 9

Welcome to @WUSTL_EM #EMConf, the #FOAMed Edition. The purpose of this weekly column is to identify #FOAMed resources that reinforce and expand on the concepts/facts discussed during weekly conference. Please post additional resources as comments below or tweet to @WUSTL_EM.

1. Trauma in Pregnancy by @rbavs
- Excellent run-down of the pearls & pitfalls of trauma resus in pregnancy by emDocs, including the precarious ventilatory status of pregnant patients at baseline and the general safety of trauma CT imaging as needed, as covered by Dr. Bavolek.
- Question-and-Answer based review of the challenges posed by physiologic changes of pregnancy when evaluating the pregnant trauma patient by @precordialthump at LifeInTheFastLane.
- And the follow up, monitoring & management of this patient – LifeInTheFastLane
- Review the EAST guidelines your trauma surgery colleagues will likely be following, from @cliffreid on
- Pro-tips for utilizing FAST exam in the pregnant trauma patient from the EDE Blog. Remember sensitivity is decreased in pregnancy, particularly in later term, and only a tiny amount of fluid posterior to the lower part of the uterus can be considered “physiologic.”

2. Pediatric Sexual Abuse by Dr. Jamie Kondis
- Excellent podcast from the PEM ED Podcast covering the cornerstone exam findings and red flags in pediatric abuse cases.
- High-yield discussion from January 2014 EM:RAP about the approach to the potential pediatric abuse patient.
- Pediatric EM Morsels with a brief piece on exam findings in pediatric abuse – remember there’s really no such thing as a “pathognomonic” bruise or fracture.

3. Morel Lavallée by Dr. Lucy Hormberg
- Learn more about the diagnosis and management of this uncommon but not unheard-of closed degloving injury from the sage minds at St. Emlyn’s.
- Review the ultrasound and MRI features of these lesions on Radiopaedia. 

4. The EKG in Acute ACS by Dr. Lucy Hormberg
- In an interview with @emcrit, @smithECGblog covers several difficult-to-diagnose ACS cases.
- Don’t miss a posterior MI. Review the EKG signs with this UMEM Educational Pearl. 
- Likewise, don’t miss an inferior MI. Review with LifeInTheFastLane. 
- Pericarditis can be difficult to distinguish from ACS. Let the guru of ED EKG himself, @amalmattu, talk you through it during this ECG Case of the Week.
- Another lecture from the great @amalmattu about the significance of changes in the Forgotten Lead, aVR. 

5. Door to Donut: ED Management of PE-likely Patients, by Drs. Gabe Gomez and Kevin Baumgartner
- Simple algorithm to review the workup of potential PE by @emcrit. Includes a link to a 2015 review article by the master of ED PE, @klinelab.
- Notes from an excellent lecture from the All NYC EM Conference covering the assessment of risk of PE in ED patients, posted at emDocs. 
- Applications and limitations of the PERC rule, also from emDocs. 
- Excellent summary of EKG changes seen in RV dysfunction due to PE from ALiEM – important to know as these patients have significantly higher mortality. 

6. Altered Mental Status in the Critically-Ill Patient, by Dr. Brian Wessman.
- Remember, what you start in the ED carries over to the ICU.
- The key to adequate sedation post-intubation is analgesia, as covered by @emcrit.  
- Use a scale to measure effect and titrate your sedation infusions. Again, analgesia first, with spot dosing of another agent (such as benzodiazepine) as needed. Check out this summary from emDocs. 

Never stop learning,
Sam (@CSamSmithMD) and Louis (@Lgaard)

EKG Challenge Case Conclusion: The EKG Sign Formerly Known as Prince?

On a Sunday afternoon, an elderly gentleman is brought into the emergency department by his wife complaining of chest pain that began one hour ago.  He is diaphoretic and appears very uncomfortable.  An EKG is obtained.  The patient has no prior EKGs available.

When you first look at the EKG, you note that there appears to be an abundance of PVCs... ventricular trigeminy actually.  Given the patient's clinical appearance, you suspect an acute MI.... now to just sort out the EKG to support your clinical gestalt.

Given the prevalence of ventricular ectopy,  you begin your analysis by identifying sinus beats [although you can use PVCs as well - see these posts (1) and (2)  on Dr. Smith's ECG blog]:
Sinus beats outlined in blue.  Other beats are premature ventricular contractions (PVCs)
 If you take one sinus tracing for each lead:

Secondly, you observe that the tracing follows left bundle branch block (LBBB) morphology.  New LBBB may be considered the criteria "formerly known as" an indication for cath lab activation.

The 2004 ACC/AHA STEMI guidelines included new LBBB as a indication for Cath lab activation in patients presenting with symptoms suspicious for acute MI.  This was changed in the 2013, largely due to data suggesting that this was responsible for a large number of "false positive" cath lab activations [1].  Two separate studies involving patients with LBBB evaluated for suspected STEMI found an overall low prevalence of coronary lesions amenable to PCI [2,3].

In "normal" LBBB, repolarization is characterized by ST segment and T wave deviation away from the major direction of the terminal QRS waveform - also known as "appropriate discordance" [1]. Hence, in leads where the QRS is positive, the ST segment (and often the T wave) are deflected in the opposite direction and vice versa:

Appropriate discordance makes it more difficult, but not impossible, to assess for acute myocardial infarction with underlying LBBB.  In 1996, Sgarbossa and colleagues retrospectively derived and independently validated a clinical prediction rule for EKG diagnosis of acute myocardial infarction in the context of LBBB using positive biomarkers as a gold standard [4].   These three criteria are illustrated in the figure below:

Image source: ecg12lead; Table source: Sgarbossa et. al. (1996)

There are few important things to note about the Sgarbossa criteria.  First, Sgarbossa criteria only need to be met in a single lead.  Second, the three criteria are not equal in their sensitivity or specificity with respect to predict myocardial infarction and thus are awarded different points within the model.   In the initial study, concordant ST elevation was found to have a sensitivity of 73% (95% CI 64-80) and specificity of 95% (95% CI 86-96), while concordant ST segment depression had a sensitivity of only 25% (95% CI 18-34) and specficity of 96% (95% CI 91-99).   The third criteria, discordant ST segment elevation > 5 mm, has a sensitivity of 31% (95% CI 23-39) and specificity of 92% (95% CI 85-96).  Thus, the Sgarbossa criteria were specific, but not necessarily sensitive, for acute myocardial infarction as diagnosed by positive biomarkers.

Source: Sgarbossa et. al. (1996)

A meta-analysis of subsequent studies evaluating the Sgarbossa criteria was published in 2008 [5].   Based on calculated sensitivities and specificities (see below), this study recommended at the Sgarbossa score of > 3 (i.e. only concordant ST elevation anywhere  or concordant ST depression in V1, V2 or V3) physicians should treat for acute myocardial infarction.  A Sgarbossa score of 2 (i.e. meeting the discordant criteria alone) was deemed "inadequate to diagnose myocardial infarction."

Source: Reference 5

Smith et. al. (2012)  addressed the low sensitivity of the initial Sgarbossa criteria by postulating that changing the third component (excessive discordance) to a proportional rule instead of a 5 mm absolute cutoff would increase both the sensitivity and specificity of the criteria.  They defined "Abnormal, excessive discordance" as a ST/S ratio of < < -0.25. 
Image Source: Smith et. al. (2012)
The authors proposed a "modified" unweighted Sgarbossa criteria:

            1. Concordant ST elevation > 1 mm in any lead
            2. ST segment depression > 1 mm in V1, V2 or V3
            3. ST/S ratio < -0.25 in any lead with > 1 mm of ST segment elevation or depression

The EKG was considered positive for ischemia if any of the above criteria were met.

Based on a data set using angiographic occlusion or troponin value > 10 ng/mL as their cutoff for "true MI", they calculated a sensitivity of 91% (95% CI 76-98) and specificity 90% (83-95) for the Modified Sgarbossa criteria.

If we apply the Sgarbossa and Modified Sgarbossa criteria to our patient's EKG, the patient meets criteria for acute myocardial infarction.

The patient did go to the cardiac catheterization laboratory and was found to have a 100% occlusion of the mid-LAD:
Cath lab diagram demonstrating 100% occlusion of mid-LAD
So what would happen if this patient did not meet Sgarbossa criteria?  Remember Sgarbossa criteria are far from sensitive.  The modified Sgarbossa criteria significantly improve on this, but has not yet been validated in a distinct set of EKGs.  What would you do?

When this patient presented, the cardiologist was at first reticent to take him to the cath lab.  Rather than arguing technicalities on a Sunday afternoon, the attending physician, Heather Webb (@webbmd) used what I would say are some of the most important criteria in a patient who looks sick and has severe chest pain, diaphoresis and a presumed new left bundle branch block to demand that the patient go: Clinical Gestalt.

Take Home Points: Left bundle branch block makes the diagnosis of acute myocardial infarction more difficult.  The original Sgarbossa criteria developed in 1996 aimed at identifying myocardial infarction in the context of LBBB were specific but poorly sensitive.  These were improved with development of the Modified Sgarbossa criteria, which incorporated the concept for proportionality in the evaluation of ST/S discordance.  Remember that these rules do not fully account for  your pretest probability or clinical gestalt of when a patient is having an MI.  If the patient looks like they are having an MI and has a new left bundle branch block, they should probably go to the cath lab regardless.  Now for Prince's Song of the Heart...

Submitted by Maia Dorsett, PGY-4 (@maiadorsett)
Faculty Reviewed by Doug Char and Joan Noelker

Interested in reading additional resources (Thanks to @tbouthillet for sharing):
 -  ECG Medical Training  on the Modified Sgarbossa criteria
- Dr. Smith's ECG blog on Modified Sgarbossa criteria with links to additional cases
- ALiEM discussion of Modifed Sgarbossa criteria with management algorithm for new LBBB

1. Cai, Q., Mehta, N., Sgarbossa, E. B., Pinski, S. L., Wagner, G. S., Califf, R. M., & Barbagelata, A. (2013). The left bundle-branch block puzzle in the 2013 ST-elevation myocardial infarction guideline: from falsely declaring emergency to denying reperfusion in a high-risk population. Are the Sgarbossa Criteria ready for prime time?. American heart journal, 166(3), 409-413.
2. Larson, D. M., Menssen, K. M., Sharkey, S. W., Duval, S., Schwartz, R. S., Harris, J., ... & Henry, T. D. (2007). “False-positive” cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. Jama, 298(23), 2754-2760.
3.Jain, S., Ting, H. T., Bell, M., Bjerke, C. M., Lennon, R. J., Gersh, B. J., ... & Prasad, A. (2011). Utility of left bundle branch block as a diagnostic criterion for acute myocardial infarction. The American journal of cardiology, 107(8), 1111-1116.
4. Sgarbossa, E. B., Pinski, S. L., Barbagelata, A., Underwood, D. A., Gates, K. B., Topol, E. J., ... & Wagner, G. S. (1996). Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. New England Journal of Medicine, 334(8), 481-487.
5. Tabas, J. A., Rodriguez, R. M., Seligman, H. K., & Goldschlager, N. F. (2008). Electrocardiographic criteria for detecting acute myocardial infarction in patients with left bundle branch block: a meta-analysis. Annals of emergency medicine, 52(4), 329-336.
6. Smith, S. W., Dodd, K. W., Henry, T. D., Dvorak, D. M., & Pearce, L. A. (2012). Diagnosis of ST-elevation myocardial infarction in the presence of left bundle branch block with the ST-elevation to S-wave ratio in a modified Sgarbossa rule. Annals of emergency medicine, 60(6), 766-776.

“Pinky and the Brain…..”

Originally posted on "Sweat the small stuff....":

Hi readers! If you’d ask me about my knowledge of brain injuries, I would have given you a gormless look much similar to Pinky’s one to Brain….

Then I went to a wonderful conference day this week organised by the Kent, Surrey & Sussex Air Ambulance. It was on Brain Injuries (traumatic and medical) and had some eminent speakers, including  Richard Lyon, Mark Wilson, Gareth Davies, Alistair Nichol and Kevin Fong. It was chaired by Dr Malcolm Russell. As the title of this post suggests, I am “Pinky” and all the speakers are collectively “Brain”

KSS Hems is a very special organisation for me for many reasons. Through out the day I was tweeting some learning points with the #KSSBrain. (Click on the hyperlink…

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