An EMS Guide to Scromiting & Cannabis-Related Emergencies

Introduction to Cannabis-Related Emergencies

With the legalization and increased potency of cannabis across many regions, emergency medical services (EMS) are encountering a rise in marijuana-related emergencies. These range from a newly recognized vomiting syndrome – colloquially called “scromiting” (a portmanteau of screaming and vomiting) – to cardiovascular crises, acute psychiatric episodes, pediatric poisonings, and other life-threatening complications.

Contrary to the common perception of marijuana as a benign substance, evidence-based data reveal significant acute side effects that EMS providers must be prepared to recognize and manage. This report (aka "field guide") provides a detailed overview of cannabis-induced syndromes and their prehospital management, helping EMS leaders shape protocols and prepare crews for these emerging challenges.

Key objectives of this guide include:

Describing Cannabis Hyperemesis Syndrome (CHS) – the condition underlying “scromiting” – including its signs, symptoms, and pathophysiology.

Outlining prehospital management strategies for CHS and differentiating it from other causes of intractable vomiting.

Reviewing other acute side effects of marijuana use, including cardiovascular, neuropsychiatric, respiratory, and pediatric considerations, with emphasis on those that can be life-threatening.

Citing case studies and real-world examples to illustrate the presentation and management of these marijuana-related emergencies.

Providing protocol recommendations based on emerging evidence to ensure EMS teams can safely and effectively care for patients with cannabis-induced complications.

Recognizing Cannabinoid Hyperemesis Syndrome - “Scromiting”

Cannabinoid Hyperemesis Syndrome (CHS) is a paradoxical condition in which chronic cannabis use leads to recurrent episodes of severe nausea, intractable vomiting, and abdominal pain. It has been nicknamed “scromiting” because patients often scream in visceral discomfort while vomiting profusely.

CHS typically emerges in patients with a history of prolonged, high-frequency cannabis use (often daily use for years). A nearly pathognomonic history finding is compulsive hot bathing – patients discover that hot showers or baths temporarily relieve their symptoms. This unique behavior, along with the cannabis use history, helps distinguish CHS from other causes of cyclic vomiting.

Clinical features: CHS usually follows a cyclical pattern with symptom-free intervals between bouts. It is often described in three phases:

Prodromal Phase: Lasts months or years; characterized by morning nausea, mild vomiting, and anxiety around vomiting, yet normal appetite and continued cannabis use. Patients may use more cannabis thinking it helps nausea, which ironically worsens the cycle.

Hyperemetic Phase: Marked by unrelenting nausea, violent retching, and vomiting that can occur dozens of times per day. Patients are unable to tolerate oral intake, leading to dehydration and weight loss. They often seek emergency care repeatedly during this phase. The compulsive hot showers behavior is typically present, as heat provides transient relief of symptoms – some CHS patients even sustain burns from prolonged hot bathing in desperate attempts to alleviate nausea. Abdominal pain is common in this phase, generally diffuse and crampy.

Recovery Phase: If cannabis use is halted, patients gradually recover over days to weeks, with symptoms resolving and normal eating habits resuming. However, relapse is common if cannabis use is resumed.

Because CHS is a diagnosis of exclusion, many patients endure extensive medical workups (for conditions like gastritis, ulcer, gallbladder disease, etc.) before CHS is recognized by clinicians. On average, one case series found CHS patients had about 7 ED visits and up to 9 years delay before receiving the correct diagnosis.

EMS providers should maintain a high index of suspicion for CHS in young, otherwise healthy patients with recurrent unexplained vomiting and a heavy marijuana use history. Targeted history questions about cannabis use frequency and hot shower habits are critical. Early recognition in the field can prevent unnecessary interventions and focus care on appropriate management.

Pathophysiology: The exact mechanism of CHS remains under investigation. Cannabis contains cannabinoids (THC, etc.) that usually have anti-emetic effects via central cannabinoid-1 (CB1) receptors, which is why cannabis can treat chemotherapy nausea. Paradoxically, in chronic use these receptors may become dysregulated. One theory is that chronic overstimulation of CB1 receptors in the brain and gut disrupts the body’s nausea/vomiting control, ultimately promoting vomiting. Additionally, cannabinoids influence the transient receptor potential vanilloid-1 (TRPV1) receptors (involved in pain and temperature regulation); stimulation of TRPV1 by heat or capsaicin appears to relieve CHS symptoms. This correlates with patients’ hot bathing behavior and the observed efficacy of topical capsaicin cream in some cases. Another factor is the changing composition of modern cannabis: today’s marijuana is far higher in THC (psychoactive) and lower in CBD (which has some modulating effects) than in decades past. Heavy daily users may accumulate large reservoirs of THC in body fat, and this persistent exposure may trigger the hyperemesis syndrome. Ultimately, continued cannabis use propagates the cycle, and only cessation leads to full resolution.

Complications: While CHS itself is rarely fatal, the consequences of protracted vomiting can be serious. Patients commonly develop dehydration and electrolyte imbalances (e.g. hypokalemia). Acute kidney injury may occur from volume depletion. Repeated forceful retching can cause Mallory-Weiss tears or, in extreme cases, esophageal rupture (Boerhaave’s syndrome), a life-threatening emergency.

Aspiration of vomit is another risk, potentially leading to aspiration pneumonitis or pneumonia. EMS providers should be alert to these potential complications in any CHS patient – for instance, chest pain and subcutaneous emphysema in a vomiting patient could signal esophageal rupture, requiring rapid transport and surgical intervention.

Case example: A 29-year-old male with long-standing daily marijuana use began suffering monthly bouts of intense vomiting and abdominal pain. Over a year, he visited the ED multiple times; tests for ulcers, gallstones, and pancreatitis were all normal. Each time, IV fluids and ondansetron provided little relief.

Notably, his spouse reported he would sit in hot showers for hours to ease the nausea. Finally, a clinician recognized the pattern as Cannabinoid Hyperemesis Syndrome. The patient was advised to quit cannabis. He struggled with cessation, relapsed, and returned with “scromiting” episodes three more times. Only after engaging in a cessation program did the cycle break. This case underlines how recognizing CHS and counseling cessation can prevent repeated suffering.

Prehospital Management of Cannabis Hyperemesis

Managing CHS in the field is largely supportive, as no rapid “antidote” for CHS exists aside from stopping cannabis use.

Key prehospital steps include:

Airway protection: Patients may vomit profusely and continuously. Position them lateral recumbent if altered to reduce aspiration risk. Suction readily if needed. Be prepared to assist ventilations if severe vomiting leads to airway compromise or if the patient’s mental status is depressed (though CHS patients are usually alert, just in distress).

Hydration and IV access: Start IV fluids (e.g. normal saline) to treat dehydration from fluid losses. Many CHS patients are volume depleted and tachycardic; fluid resuscitation can improve perfusion and symptoms. Obtain blood samples if possible, as ED will often check electrolytes (particularly potassium).

Antiemetics: Traditional antiemetic medications often have limited effect in CHS, but they are reasonable to attempt in the acute setting. Ondansetron (4–8 mg IV) or metoclopramide can be given per protocol, though CHS vomiting typically proves resistant to these first-line agents.

If your system carries benzodiazepines (like lorazepam) for severe nausea or anxiety, these may provide some relief as adjuncts. Importantly, some EMS protocols now recognize that haloperidol or droperidol (antipsychotics) can be very effective antiemetics in CHS. Small case series and ED studies have shown haloperidol can rapidly relieve CHS symptoms when other drugs fail. If permitted (and if no contraindications like prolonged QT), a dose such as haloperidol 5 mg IM/IV could be considered for intractable vomiting with medical control consultation. This intervention has been successful in multiple reports – for example, one ED study found haloperidol superior to ondansetron for CHS symptom relief. Monitor the cardiac rhythm if using droperidol/haloperidol, as these can prolong QT (though CHS patients are often young and low risk for torsades, caution is advised).

Symptomatic relief measures: If feasible, allow the patient to continue a warm shower or apply warm packs to the abdomen – this is unconventional in EMS, but given patients know this helps them, it might provide comfort enroute. Some EMS agencies have anecdotal reports of using topical capsaicin cream (available in some first aid kits for muscle pain) applied to the patient’s abdomen; capsaicin acts on the same receptors stimulated by heat and has shown benefit in CHS. This isn’t a standard EMS treatment, but it’s an interesting adjunct if protocols evolve (it has low risk, causing just local warmth/burning sensation).

Pain management: Abdominal pain in CHS can be severe. Avoid opioid analgesics if possible, or use sparingly, because opioids can slow gastric emptying and may worsen vomiting in CHS. Opioids also can alter mental status and thus complicate evaluation. Non-narcotic options (acetaminophen if tolerated orally, or IV acetaminophen/ketorolac if available and not contraindicated) are preferred. However, if pain is excruciating and vomiting is constant, small doses of IV fentanyl could be justified for comfort, balancing the risks.

Differential diagnosis: Do not automatically assume chronic cannabis use means CHS is the cause of vomiting. Remain vigilant for other emergencies that cause abdominal pain and vomiting (e.g. appendicitis, bowel obstruction, pancreatitis, etc.).

Assess for red flags: focal abdominal tenderness, peritonitis, bloody vomit, high fever, or significant vital sign abnormalities should prompt consideration of surgical or infectious causes over CHS. In female patients of childbearing age, consider pregnancy-related issues (hyperemesis gravidarum, ectopic pregnancy). If the patient’s presentation is atypical for CHS (for instance, no relief with hot bathing, or only short-term cannabis use), be cautious about labeling it CHS prematurely. When in doubt, treat supportively and transport for further evaluation.

Psychological support and education: CHS episodes can be extremely distressing. Patients may be anxious (“am I dying?”) and embarrassed. Provide calm reassurance that you suspect a known syndrome caused by their cannabis use. While prehospital providers can’t force a behavior change, educating the patient that continuing to use cannabis will likely perpetuate their suffering is important. Emphasize that cessation is the only definitive cure. Many patients are skeptical (after all, cannabis helped their nausea in the past), so a compassionate explanation during transport can lay groundwork for them to accept counseling later.

Transport Priority: CHS itself is uncomfortable but not an immediate “lights and sirens” life threat unless complications are present. However, if the patient has unstable vital signs (e.g. hypotension from dehydration) or concerning features (severe electrolyte disturbances, aspiration risk), treat it as an acute emergency. In most cases, prompt yet non-urgent transport to the ED for IV hydration, electrolyte repletion, and further management is appropriate. Alert the receiving facility if you suspect CHS – this can expedite their care (they might skip another CT scan and focus on symptom control and referral).

By recognizing CHS in the field, EMS can significantly improve patient outcomes. Identifying the syndrome not only guides more effective prehospital care (targeted treatments like haloperidol, avoiding harmful meds, etc.) but also helps reduce unnecessary tests and delays in the hospital. Moreover, it gives EMS an opportunity to educate the patient on the need to quit cannabis, potentially preventing future 9-1-1 calls for the same issue. As cannabis use rises, EMS agencies should incorporate CHS recognition and management into their training and protocols.

Cannabis and the Cardiovascular System: Acute Cardiac Emergencies

One of the most concerning – and sometimes life-threatening – effects of marijuana involve the cardiovascular system. THC (tetrahydrocannabinol), the main psychoactive component, has complex interactions with the autonomic nervous system and cardiac electrophysiology. In moderate doses, THC typically causes tachycardia and mild hypertension due to sympathetic stimulation. Users often experience their heart “racing” shortly after smoking.

However, high doses can paradoxically lead to bradycardia and hypotension via vagal stimulation. This dose-dependent biphasic effect means cannabis can both trigger rapid arrhythmias and, in some cases, severe brady arrhythmias or syncope. EMS providers should be aware of several specific cardiac events associated with marijuana use:

Arrhythmias (Atrial fibrillation and others): Multiple studies indicate cannabis use can precipitate cardiac arrhythmias, especially atrial fibrillation (AF) in younger patients with no other risk factors. In a review of cannabis-related arrhythmia cases, about 26% were AF and another 22% were life-threatening ventricular fibrillation (VF) arrests. The mechanism may involve THC increasing myocardial oxygen demand and sympathetic drive, while also affecting cardiac ion channels (such as blocking the hERG potassium channel, which can lengthen QT interval). Cannabis can thus create an electrically unstable cardiac environment.

Case report: One dramatic example involved a 15-year-old boy who went into asystole, then ventricular fibrillation, after smoking cannabis – the first documented pediatric cannabis-induced cardiac arrest.

More recently, a 26-year-old woman with chronic cannabis use suffered sudden cardiac arrest due to VF; on hospital arrival her QTc was markedly prolonged at 483 ms, though her coronary arteries were clean. She fortunately survived, and no cause other than cannabis was found for her arrhythmia.

These cases underscore that even in healthy young people, cannabis can trigger fatal arrhythmias. From an EMS perspective, if you respond to a cardiac arrest, especially in a young adult, and learn the patient or bystanders report recent marijuana use, keep a high index of suspicion for cannabis as a contributing cause once ROSC is achieved. Also be mindful of arrhythmias in conscious patients: if a patient who has recently used marijuana complains of palpitations, dizziness, or chest discomfort, assess for irregular pulse or tachyarrhythmias.

Cannabis-related AF may present as a rapid irregular heartbeat in a young person with no history of heart disease. Standard arrhythmia management (rate control, vagal maneuvers, ACLS protocols if unstable) should be applied. In the case of cannabis-induced bradyarrhythmias, such as sinus node arrest and pauses, treatment is supportive – ensure oxygenation, establish IV access, and be ready to give atropine or initiate pacing if severe bradycardia causes hemodynamic compromise. For example, one report described a 54-year-old woman who had repeated sinus arrests (4.6-second pauses) and near-syncope immediately after smoking 1 g of marijuana. Her symptoms (lightheadedness, tingling, presyncope) resolved spontaneously in a few hours. This was likely due to an extreme vagal response to a large THC dose.

In such scenarios, EMS should monitor the patient’s ECG and be prepared for possible asystole – lying the patient supine and elevating legs can help, and external pacing pads should be applied if pauses are prolonged. Notably, orthostatic hypotension and vasovagal syncope can be triggered by cannabis, so syncope after marijuana use should be treated as any fainting – check blood pressure, consider orthostatic vitals, and assess cardiac rhythm, as cannabis-related syncope could herald sinus node dysfunction or high-degree AV block in that moment.

Myocardial Infarction (MI): Cannabis is increasingly recognized as a trigger for acute coronary syndromes, including MI, even in people with clean coronary arteries. THC causes a rise in heart rate and blood pressure, increases cardiac oxygen demand, and may cause coronary vasospasm and promote platelet aggregation – a perfect storm for precipitating an MI.

Research has shown that within one hour of smoking cannabis, the risk of onset of MI is about 4.8 times higher than baseline. This elevated risk was noted in a multicenter study and suggests marijuana can act similarly to physical exertion or extreme stress as an immediate trigger for MI. Epidemiological data also show higher rates of MI in habitual cannabis users: a recent analysis of young adults (ages 18–44) found those who used marijuana frequently had double the odds of having had a heart attack compared to non-users (adjusted OR ~2.0).

Another national survey study (Journal of the American Heart Association, 2024) reported that daily cannabis users had 25% higher odds of heart attack than non-users. In many cases, these MIs are of the type MINOCA (MI with non-obstructive coronary arteries) – meaning the patient’s coronary angiogram shows no significant plaque, implicating factors like vessel spasm or a transient thrombus that resolved.

EMS should treat chest pain in a cannabis user with the same high suspicion as any chest pain. Do not dismiss a 20-something’s chest pain as “just anxiety from weed” – there are documented fatalities from patients ignoring MI symptoms after cannabis use. Perform a 12-lead ECG early. Cannabis-triggered MI may present with classic ischemic ECG changes (ST elevations or depressions) or sometimes just tachycardia and palpitations. Provide oxygen if hypoxic, give aspirin if not contraindicated, and follow chest pain protocols (nitroglycerin can be given if blood pressure allows, keeping in mind that cannabis users may have variable BP responses). Pain management with fentanyl may be appropriate in severe chest pain and be prepared for dysrhythmias (VF arrest can occur in the setting of an acute MI – all the more reason to obtain IV access, attach defibrillation pads if ECG is concerning, etc.).

One case report describes a 21-year-old male who experienced ST-elevation MI soon after marijuana use, attributed to coronary spasm; fortunately, he survived with prompt treatment. Another case involved a young man with a myocardial bridge (a congenital coronary anomaly) who had a non-obstructive MI after cannabis – highlighting that sometimes an underlying subtle heart condition can be unmasked by marijuana’s cardiac effects.

The bottom line: if a patient has chest pain or acute coronary syndrome signs after using cannabis, activate the cath lab as needed and manage per ACS protocols. Marijuana is not cardio-protective – in fact, multiple studies now implicate it in higher rates of MI, arrhythmias, stroke, and even sudden cardiac death.

Cardiac arrest and sudden death: In rare instances, cannabis use has led directly to cardiac arrest. Mechanisms include malignant arrhythmias (as discussed with VF) or possibly profound brady asystolic events in susceptible individuals. The case of the 26-year-old female who went into VF after heavy cannabis use is instructive: she had no heart disease, yet cannabis likely prolonged her QT and triggered the arrest. About 11% of reported cannabis-related arrhythmia cases in one review were fatal.

EMS arriving to a cardiac arrest should consider toxins in the differential (including cannabis, especially if there are bystanders mentioning recent use or if the patient is young). While management won’t differ in the moment (high-quality CPR, defibrillation, ACLS), knowing cannabis is a possible cause might influence post-ROSC care (e.g. alerting the hospital to check toxicology, focusing on cardiac ICU care for arrhythmia monitoring). If ROSC is obtained, the patient should be monitored for recurrent dysrhythmia – cannabis-induced VF can recur if the trigger (THC and its metabolites) is still active at high levels.

Case follow-up: The aforementioned 26-year-old survived but had an anoxic brain injury from her arrest and required prolonged neurorehabilitation. Her cardiac function and QT normalized after a few weeks, reinforcing that THC was the likely reversible trigger of her cardiac arrest. This case should raise awareness among EMS: marijuana is not harmless – it has real potential to cause life-threatening cardiac events.

EMS approach to cannabis-related cardiac events: Always perform a thorough assessment. Check blood pressure and heart rate; cannabis users could be tachycardic (most commonly) or in some cases bradycardic with hypotension if they consumed a very large dose or if they had a vasovagal syncopal event. Obtain an ECG early for any patient with syncope, palpitations, or chest pain who has been using marijuana. Look for arrhythmias or ischemic changes. Monitor the patient continuously during transport. If an arrhythmia is present:

Tachyarrhythmias: Treat per ACLS. For narrow complex tachycardia (SVT), attempt vagal maneuvers and adenosine if indicated. For A-fib with rapid ventricular response, if the patient is unstable, consider synchronized cardioversion; if stable, rate control with diltiazem or beta blockers can be initiated in-hospital (prehospital use of these is usually limited). For wide-complex tachycardia (VT) in a cannabis user, assume it could degenerate into VF – prepare for immediate cardioversion/defibrillation as needed. VF or pulseless VT should be defibrillated promptly; standard resuscitation drugs (epinephrine, amiodarone) apply. There’s no special anti-arrhythmic for cannabis-induced VF; treat it like any sudden cardiac arrest. If ROSC, consider transport to a cardiac center capable of intensive monitoring and possible coronary angiography (especially if an MI is suspected).

Bradyarrhythmias: In a scenario of bradycardia with hypotension after marijuana use (for example, an extreme case of cannabinoid-induced vasovagal response), follow bradycardia algorithms. Atropine 0.5 mg IV can be given if there’s significant bradycardia causing hypotension or dizziness. If ineffective and the patient is unstable, be ready to initiate transcutaneous pacing. However, many cannabis-related brady arrhythmias (like sinus pauses) are transient. Keep the patient supine, establish IV access, and monitor – often the heart rate will improve as the acute effect wears off. Nonetheless, do not underestimate it: there are case reports of asystole after cannabis use requiring pacing. One young male had repeated asystolic pauses after very heavy marijuana intake (dozens of bong hits); he had underlying congenital heart disease, but it shows cannabis can precipitate extreme vagal episodes Therefore, treat symptomatic bradycardia seriously and be prepared with the full bradycardia protocol.

Chest pain/MI: As noted, follow chest pain protocols. One challenge is that younger patients or those who are high may not communicate symptoms clearly – they might just feel “weird” or anxious rather than classic crushing chest pain. Maintain a broad differential for any altered mental status or ill appearance in a cannabis user, including the possibility of acute coronary syndrome. If the patient is significantly diaphoretic, ashen, with vomiting and chest pain (symptoms that could be misinterpreted as too high or anxious), consider that they might be having an MI. Use capnography if available to monitor ventilations, especially if patients have taken other substances that could depress respirations.

Key Takeaway: Cannabis can stress the heart in multiple ways: increasing cardiac workload, causing dysrhythmias, and instigating acute coronary events. EMS providers should approach cannabis-using patients with appropriate vigilance.

Do not assume that because the drug is “natural” or legalized that it cannot be the culprit of serious medical problems. As one medical review starkly concluded: “Medical marijuana is a drug with potentially life-threatening side effects, and it affects the cardiovascular system in a number of ways even in young adults.” EMS protocol should encourage obtaining a substance use history for all patients with cardiac complaints – asking specifically about cannabis use – and incorporate that knowledge into assessment and hospital notification.

Neuropsychiatric Side Effects of Marijuana

Cannabis primarily affects the central nervous system, and it can precipitate a spectrum of neurological and psychiatric emergencies. EMS responders frequently encounter patients who are acutely intoxicated with marijuana, presenting with symptoms ranging from severe anxiety attacks to full-blown psychosis or bizarre behavior. Understanding these presentations and their management is key, especially as high-potency THC products (including edibles and concentrates) become more common.

Acute Anxiety and Panic Reactions: Many cannabis users experience anxiety, panic, or paranoia after a high dose. This is often seen in naïve users or after ingesting edibles, which have delayed and potent effects. The patient may have symptoms indistinguishable from a panic attack: hyperventilation, chest tightness, palpitations, trembling, a sense of impending doom, and fear of dying.

They might be extremely agitated or terrified, sometimes begging for help. From an EMS perspective, it’s important to stay calm and reassure these patients. Introduce yourself clearly and speak in a gentle, soothing tone. Often, a quiet environment away from onlookers can help de-escalate the anxiety.

Coach the patient’s breathing if they are hyperventilating – simple techniques like breathing with them, giving them a re-breathing mask (not connected to oxygen) or bag to rebreathe CO₂ (if hyperventilation is severe) can prevent respiratory alkalosis. Check vital signs; tachycardia and elevated blood pressure are common in panic and cannabis intoxication. If the patient is hypertensive or tachycardic, ensure it’s from anxiety and not another medical issue (like an arrhythmia or MI as discussed prior).

In most cases, pure cannabis-induced panic will improve with time and reassurance. However, if the anxiety is extremely severe or bordering on psychosis, pharmacological intervention may be needed. EMS may consider a benzodiazepine (e.g. midazolam or lorazepam) per protocol for acute anxiety agitation. This can both calm the patient and prevent escalation to dangerous agitation. Titrate to effect – the goal is to ease panic, not to overly sedate or cause respiratory depression. Always monitor the patient’s airway and breathing if medication is given. Importantly, exclude other causes of acute anxiety or altered mental status: hypoglycemia, intoxication with stimulants (sometimes people mix cocaine or meth with cannabis), or medical illnesses (thyroid storm, etc.). If the patient’s presentation is not clearly just anxiety (for example, they have hallucinations or vital sign extremes), treat accordingly as described below.

Cannabis-Induced Psychosis: High doses of THC can induce acute psychotic episodes, especially in individuals with underlying mental health vulnerabilities or adolescents with developing brains. Features of cannabis psychosis include paranoia, delusions, hallucinations (often auditory), and disorganized behavior. The person may not recognize you as a helper – they could be paranoid that EMS (or police) intend to harm them. This obviously creates safety concerns. Scene safety is paramount; consider law enforcement assistance if the patient is a danger. Approach in a non-threatening manner but have a plan for rapid control if violence erupts. According to mental health research, about 25–30% of cannabis-related ED visits are for acute psychological symptoms (anxiety or psychosis). Moreover, up to half of patients who experience cannabis-induced psychosis requiring hospitalization later develop a chronic psychotic disorder like schizophrenia. So, these episodes are not always transient or benign.

Prehospital management of acute psychosis centers on ensuring the safety of the patient and crew and reducing stimuli. Try verbal de-escalation techniques: listen to the patient’s fears, avoid arguing with any delusions, and maintain a safe physical distance until trust is gained or until restraint is needed. If the patient is severely agitated, posing a risk of harm to themselves or others, chemical and/or physical restraint should be implemented per protocol. Benzodiazepines can be used for sedation (e.g. midazolam IM/IV), or antipsychotics like haloperidol/droperidol can be considered for tranquilization if in scope. Some EMS systems use a combination (e.g. haloperidol with lorazepam) for excited delirium or severe agitation – this may be applicable for a “bad trip” or THC psychosis as well. Always monitor airway and breathing in a restrained, sedated patient. Remember these patients might also have medical issues due to their psychosis: for instance, an agitated person might have injured themselves (lacerations, jumping out a window in paranoia, etc.), so do a quick trauma assessment if indicated. Check blood glucose as well; acute psychosis could mask hypoglycemia symptoms.

From a medical perspective, cannabis psychosis itself doesn’t have a specific antidote – treatment is supportive and symptomatic. The good news is that such psychosis usually resolves within 24-72 hours as the drug effect wears off. One case report of a 34-year-old woman who ingested a large cannabis edible described her becoming erratic and psychotic, with even some physical findings like QT prolongation and mild hypokalemia, yet with minimal interventions her psychosis and ECG changes resolved in 48 hours. EMS transported her safely after sedating her for agitation; in the ED she was primarily just observed and given fluids. This case highlights that supportive care is usually sufficient – protect the patient and others until the drug’s effects dissipate. All such patients, however, need psychiatric evaluation after medical clearance. EMS should ensure these patients are transported to an appropriate facility for further evaluation, as they may require inpatient mental health care if symptoms persist.

Additionally, it is vital to consider poly-substance use: cannabis is often used alongside alcohol or other drugs. If a psychotic patient has abnormal vital signs or exam findings not explained by THC alone, consider other intoxicants (stimulants like PCP, amphetamines, bath salts can cause similar or worse agitation). Manage accordingly with more aggressive sedation if needed and be alert for excited delirium syndrome if hyperthermia and extreme strength are noted.

Cerebral Circulation and Neurologic Events: There is growing evidence that cannabis use is associated with an increased risk of stroke, particularly ischemic stroke in young adults. The AHA Journal analysis noted daily cannabis users had 42% higher odds of stroke compared to non-users. Mechanisms posited include cannabis-induced vasospasm (similar to its effect on coronaries) and hypotension or arrhythmias leading to brain hypoperfusion.

There’s also a specific syndrome called reversible cerebral vasoconstriction syndrome (RCVS) that has been linked to marijuana use, where patients get severe headaches and strokes due to constricted brain vessels. For EMS, this means a young person with sudden neurological deficit or “thunderclap” headache and known cannabis use should still be treated as a stroke alert – don’t assume “too young for stroke.” Implement your stroke protocol (rapid glucose check, stroke scale exam, last-known-well time, notification to stroke center) as appropriate.

Another rare neuro complication in extreme THC dosing is seizures – typically, cannabis alone is not epileptogenic (in fact, CBD is used to treat seizures), but there have been occasional reports of seizure activity in synthetic cannabinoid use. Traditional marijuana can cause seizures usually only if severe hypotension or hypoxia occurs secondary to other events (e.g., cardiac arrest). So if a cannabis-using patient has a new-onset seizure, search for another cause (head trauma, other drugs, or underlying epilepsy) and treat with benzodiazepines per seizure protocols.

Driving impairment and trauma: While not a direct physiologic side effect, it’s crucial to note that cannabis intoxication impairs coordination, reaction time, and judgment. This has led to many motor vehicle crashes and trauma incidents involving cannabis. EMS crews might respond to an MVA where the driver (or all parties) is positive for THC. In such cases, manage the trauma per standard protocols, but be mindful that the patient’s mental status might be altered from the drug in addition to any head injury. It’s often a challenge to discern THC impairment from neurological injury – when in doubt, err on the side of caution and immobilize the spine, etc., as needed. Communicate to receiving staff if impairment is suspected, as law enforcement might also be involved for DUI considerations.

Protocol considerations for neuro/psych effects: EMS agencies should train providers to recognize cannabis-related mental health presentations as legitimate medical emergencies. Protocols might include “behavioral emergency – suspected substance ingestion” pathways where sedation is indicated for severe agitation. Additionally, integrating a screening question about substance use in altered mental status protocols is valuable (“Does the patient use marijuana or other drugs?”) – this can quickly guide the provider to consider CHS, cannabis psychosis, etc., as part of the differential. Remember that combining cannabis with other substances (especially hallucinogens or stimulants) can exacerbate psychiatric effects, so anticipate that those patients might need more intensive management.

Pediatric Cannabis Exposures and Toxicity

One particularly concerning development with cannabis legalization is the spike in accidental pediatric ingestions of cannabis products. Edible forms of THC (gummies, brownies, chocolates) often look like candy or snacks, enticing to young children. Kids can consume large doses unwittingly, leading to significant toxicity.

National poison control data and CDC reports confirm that since adult-use marijuana was legalized in various states, there has been a sharp rise in child cannabis poisonings, many requiring emergency care. EMS providers must be prepared to identify and treat cannabis exposure in infants and children, who may present much differently than adults.

Clinical presentation in children: Unlike adults, who typically experience euphoria or anxiety, young children tend to become overwhelmingly sedated by cannabis. Common signs include: excessive drowsiness or unresponsiveness, limpness, poor coordination (ataxia, frequent falls), and sometimes paradoxical irritability or agitation alternating with somnolence. They often appear “out of it” – for example, a toddler might be found difficult to arouse from a nap, or a previously active child is just lethargic and won’t wake up fully. Other features can include hypotonia (poor muscle tone, “floppy” appearance), bradypnea (slow breathing) or apnea in severe cases, and miosis (constricted pupils) – although pupil size can vary. Nausea/vomiting can occur, but in kids it’s less common than the CNS depression. In fact, in severe overdoses, children can progress to respiratory depression and even coma. The CDC notes that children who eat THC edibles “can become very sick” and may have trouble walking, sitting up, or breathing. There have been reports of pediatric ICU admissions and even cases requiring ventilatory support after high-dose THC ingestion.

Assessment and field treatment: When dispatched for an “unresponsive child” or child with altered mental status, keep cannabis on the differential – especially if the history is unclear or suggests a possible ingestion. Clues might be an empty package of edibles found by the parents, an older sibling who mentions the child ate “candy,” or caregivers who appear hesitant to explain what happened (sometimes due to fear of legal repercussions). If the child is indeed showing signs of cannabis effect, supportive care is the mainstay:

Airway and Breathing: This is the top priority. If the child is severely obtunded or showing signs of respiratory depression (slow or shallow breathing, SpO₂ dropping), be prepared to manage the airway. Unlike opioid overdose, there is no antidote like naloxone for THC – so if respirations are inadequate, you must provide ventilation support. Start with bag-valve-mask ventilation and supplemental oxygen. If the child cannot protect their airway or ventilation remains insufficient, endotracheal intubation may be required. An ACEP case simulation explicitly advises considering intubation if a child becomes severely bradypneic from cannabis ingestion. Children have smaller airways and a tendency for rapid desaturation, so do not delay intervention. Use Pediatric Advanced Life Support (PALS) guidelines for bradycardia that results from hypoxia – ensure oxygenation and ventilation first, as that often corrects bradycardia in kids. If cardiac arrest ensues (extremely rare from cannabis alone, but possible if hypoxia is prolonged), follow standard pediatric resuscitation.

Circulation: Most pediatric cannabis patients maintain stable blood pressure and circulation or are only mildly tachycardic from a stress response. Monitor pulse and perfusion. IV access should be obtained, if possible, both for potential medication administration and for dextrose if needed (always check finger-stick glucose in an unresponsive child – toddlers could have hypoglycemia from other causes). IV fluids can be started at maintenance rates; dehydration is usually not an issue unless they vomited or it’s a delayed presentation.

Monitoring and supportive measures: Place the child on a monitor for continuous HR and pulse oximetry. Check EKG if feasible – THC can, in rare cases, cause arrhythmias or QT changes even in kids (for instance, the 34-year-old adult with THC had QT prolongation and while that was an adult, it’s prudent to monitor a child’s cardiac rhythm too). In practice, a significant arrhythmia is unlikely, but sinus tachycardia or bradycardia should be addressed by treating the underlying respiratory status. Keep the child warm and in a recovery position if not intubated, as they won’t protect their airway if they vomit. If seizures occur (again rare from cannabis alone, but could happen, especially if there was trauma or if the edible was mixed with something), treat per pediatric seizure protocol (benzodiazepines).

No antidote: Emphasize to caregivers (and document for receiving hospital) that there is no reversal agent for cannabis toxicity. Activated charcoal could be considered in the hospital if within a certain time frame of ingestion, but typically by the time EMS arrives, the THC is already absorbed (edibles may take 1-2 hours to kick in, so there is a chance to give charcoal in ED if caught early). In the field, we generally do not administer charcoal unless explicitly directed by poison control/medical control in certain circumstances. Focus on symptomatic care and rapid transport.

Poison control: Contact poison control (1-800-222-1222) for any confirmed or strongly suspected pediatric cannabis ingestion. They can provide specific guidance and also help track these incidents epidemiologically. Poison control will usually advise supportive care and observation; they might suggest whether to transport to a pediatric specialty center if available. Document the substance (if known) – e.g., “10 mg THC gummy, x number taken” or if unknown, describe any found containers. Bring the packaging to the hospital if obtainable, as it can help confirm the substance and dose.

Transport and hospital notification: These children should be transported for further evaluation even if they’re currently stable. Effects can last for hours (some edible intoxications last 12+ hours), so the child will need monitoring until fully alert. Notify the ED early, especially if the child is very young or in need of aggressive airway management, so they can summon pediatric specialists. If intubation was done, head to a facility with PICU capabilities if possible. If the child is stable and just sedate, most EDs can handle it, but any respiratory compromise should prompt consideration of a higher-level pediatric center.

Case example: An EMS crew is called for a 2-year-old girl found unresponsive. On arrival, the toddler is limp, eyes closed, breathing shallowly at 8/min, heart rate 90 (low for age), oxygen saturation 93% on room air. The parents are distraught and mention they “found her like this after a nap.” The crew notices a torn package of chocolate cannabis edibles on the kitchen floor. They suspect THC overdose. They open the airway, begin ventilating with a BVM, and the child’s color and pulse improve. IV access is achieved, and the child is given a small fluid bolus. En route, she requires continued ventilatory support but does not need CPR. Poison control is contacted and confirms no antidote; they agree intubation may be needed if the child cannot be stimulated to breathe more. On ED arrival, the child is intubated for decreasing respiratory drive. She is admitted to the PICU, monitored, and extubated the next day after the effects wear off. She makes a full recovery. This scenario (drawn from common patterns in case reports and simulation.) demonstrates how quick EMS support of airway and breathing can be lifesaving in a pediatric cannabis poisoning.

Legal and social considerations: A pediatric cannabis poisoning also raises child safety concerns. EMS providers, as mandated reporters, should ensure that possible child neglect is considered. Often these are accidents – a parent legally (or illegally) had an edible that was not stored securely. Still, involve law enforcement if not already on scene, and document objectively what was found. Your primary job is medical care but be aware the hospital will likely involve social services to educate the family and assess the home situation. Convey any relevant scene information (like numerous drugs lying around within child’s reach, etc.) to the ED staff.

Preventive message: One educational point EMS can subtly impart to caregivers is the importance of safe storage of cannabis products. The CDC explicitly advises keeping THC edibles locked up, out of reach of kids. While on scene (after critical care done), an EMT or paramedic might mention to the parent, “Edibles can be very dangerous to little ones; be sure to lock these up to prevent this from happening again.” Nonjudgmental, but clear communication can perhaps prevent repeat incidents.

Respiratory Effects: Smoking, Vaping, and Lung Injury

Cannabis smoke inhalation can affect the respiratory system in both acute and chronic ways. While a single marijuana cigarette can cause transient bronchial dilation followed by possible bronchospasm (especially in asthmatics), acute life-threatening respiratory effects from smoked cannabis alone are uncommon. However, two areas deserve attention: vaping-related lung injuries and trauma to lung structures from chronic smoking.

EVALI (E-cigarette or Vaping-Associated Lung Injury): In 2019, an outbreak of acute, severe lung injuries occurred across the U.S., strongly linked to vaping THC-containing oils (particularly from black-market sources). This condition, known as EVALI, caused patients (often teens or young adults) to develop rapid onset breathing difficulty, hypoxia, cough, chest pain, and systemic symptoms like fever. Many were initially misdiagnosed as pneumonia until the pattern emerged. It’s believed that additives like vitamin E acetate used as a cutting agent in illicit THC vape cartridges were the primary culprit, triggering a severe inflammatory reaction in the lungs. By February 2020, over 2,800 hospitalizations and 68 deaths had been reported in the EVALI outbreak.

EMS should suspect EVALI in patients (especially under 40) with acute respiratory distress and a recent history of vaping – particularly THC vapes. Signs can include very low oxygen saturations, diffuse lung crackles, and sometimes GI symptoms (many EVALI patients had nausea, vomiting, and abdominal pain as well). Prehospital management is supportive: provide high-flow oxygen; if the patient is in severe respiratory distress, consider CPAP/BiPAP if protocol allows or prepare to assist ventilation. Many of these patients will require endotracheal intubation for ARDS-like respiratory failure. Early notification to the receiving hospital is key, as they may need to arrange for critical care. While the acute EVALI outbreak has subsided (due to public health interventions and removal of vitamin E acetate products), sporadic cases still occur. Also, homemade or counterfeit vape products remain a risk. EMS providers should ask about vaping in respiratory calls, just as they would ask about smoking history. If EVALI is suspected, alert the hospital so they can involve critical care and public health if needed. Treatment in the hospital often involves corticosteroids and supportive care, but EMS’s role is stabilization and transport.

Airway irritation and bronchospasm: Cannabis smoke, like any smoke, can irritate the airways. In patients with asthma or COPD, marijuana use can precipitate bronchospasm or trigger wheezing. Treat these patients as you would any asthma exacerbation: supplemental oxygen, bronchodilator nebulizers (albuterol/ipratropium), and if severe, epinephrine or magnesium as per protocol. Don’t hesitate to use bronchodilators for a wheezing patient who admits to smoking marijuana – the “natural” origin of the smoke doesn’t prevent it from causing an asthma attack. Chronic cannabis smokers can develop chronic bronchitis, so some patients might have baseline cough and wheeze. Approach exacerbations similarly to tobacco smokers.

Trauma to lung tissue – bullae and pneumothorax: A peculiar effect seen in heavy long-term cannabis smokers (especially those who inhale deeply and hold the smoke) is the formation of giant apical lung bullae – essentially enlarged air pockets in the lung apices that can pop and cause a spontaneous pneumothorax. Cases of young men presenting with severe bullous emphysema (“bleb disease”) in their 20s have been associated with daily marijuana smoking, even without concurrent tobacco use. These patients can develop secondary spontaneous pneumothorax due to ruptured bullae. In fact, cannabis smoking appears as a cause of bullous lung disease on some pulmonology teaching slides.

EMS might encounter a tall, thin, 25-year-old chronic marijuana user complaining of sudden one-sided chest pain and shortness of breath – classic for a popped bleb. On exam, you may find unequal breath sounds (diminished on one side), and the patient may be tachypneic and hypoxic. Treat this as a pneumothorax: provide oxygen, and if signs of a tension pneumothorax develop (tracheal deviation, jugular venous distension, hypotension – which are late signs), perform needle decompression per protocol. Most often it will be a simple large pneumothorax that needs a chest tube in the ED. The key is to consider that cannabis use doesn’t make someone immune to the same lung issues seen in cigarette smokers.

Be mindful of pneumothorax in any sudden respiratory collapse scenario and gather history about smoking of any kind. A recent case report documented a young male cannabis user with bilateral apical blebs and a spontaneous pneumothorax, reinforcing the association.

Smoke inhalation injuries: Although not a direct effect of cannabis on the body, there is a risk when users consume cannabis in concentrated forms (like hash oil extractions using butane). There have been fire incidents and explosions during amateur THC extraction, causing burn and inhalation injuries. If responding to a burn/fire scene that was a “hash oil lab,” treat any inhalation injury with high-flow oxygen, consider cyanide toxicity if plastic materials burned, and manage burns as per trauma guidelines.

Chronic effects and long-term concerns: Chronic marijuana smoking is associated with chronic bronchitis symptoms (cough, sputum) and possibly accelerated lung function decline similar to tobacco in heavy users. EMS might see chronic oxygen-dependent patients who only smoked marijuana but have COPD-like disease. Additionally, cannabis smoke contains many of the same carcinogens as tobacco smoke; however, a clear link to lung cancer is still debated (fewer pack-years typically). For EMS, these chronic issues are less acute, but awareness is useful when assessing medical history.

COVID-19 note: The COVID-19 pandemic (2020-2021) raised questions about smoking/vaping risks. Some EVALI cases might have been initially mistaken for COVID and vice versa. Continue to use PPE and consider infectious disease in acute lung injury patients but remember to also inquire about recent vaping or cannabis use as part of the history for respiratory distress – as we have multiple etiologies co-existing now.

Putting It All Together: Protocol Implications and Recommendations for EMS

As cannabis-related incidents become more frequent, EMS systems should adapt protocols to address these specific needs. Below are evidence-based recommendations and considerations for EMS leaders and providers:

1. Screening and Recognition: Implement routine screening for cannabis use in relevant chief complaints. For example:

For any patient with cyclic vomiting, add: “Ask about daily marijuana use and hot shower behavior (possible CHS)” to the nausea/vomiting protocol.

For any young patient with unexplained chest pain, syncope, or arrhythmia, add: “Consider substance use history (including cannabis)”.

For psychiatric/behavioral calls, dispatch could relay if callers mention drug use; field providers should ask about cannabis or synthetic cannabinoid use as part of their altered mental status workup. Recognizing the pattern of “scromiting” and other cannabis effects in the field can expedite proper care.

Educate crews that CHS is real and on the rise – e.g., share data that CHS cases more than doubled in Colorado after legalizing. Reinforce that hyperemesis in a cannabis user is not “drug-seeking” or fake; it is a physiological syndrome requiring compassion and proper management.

2. Treatment Protocols for CHS: Given the relative refractoriness of CHS to typical antiemetics, EMS medical directors might consider adding droperidol or haloperidol as approved treatments for intractable vomiting. Many EMS systems already carry droperidol for nausea or agitation; highlighting its use in suspected CHS could improve patient comfort (for instance, a protocol could say: “If suspect CHS and patient is in severe distress, may give droperidol 1.25–2.5 mg IV if no contraindications” – noting to monitor ECG). The supporting evidence includes case series where haloperidol resolved CHS vomiting when ondansetron did not. Also, carrying topical capsaicin cream in the ambulance as an optional treatment for pain/nausea in CHS might be an innovative addition – it’s low-cost and studies have shown significant relief in CHS with capsaicin applied to the abdomen. This could be discussed with your medical oversight and perhaps trialed.

3. Cardiac Care Updates: Ensure your ACS (Acute Coronary Syndrome) protocols do not exclude younger patients. The evidence that cannabis users have higher MI and arrhythmia risk means EMS should not have an upper age limit for activating cardiac alerts. Train crews that “Yes, a 25-year-old can have a heart attack precipitated by marijuana” – so treat the symptoms, not the age. Also, consider protocols for unexplained cardiac arrest in young patients to include toxicology blood draws (if within scope) or at least documentation that might prompt the hospital to test for THC. While it won’t change field management, knowing the cause can affect post-arrest care and future prevention.

4. Agitation/Sedation Protocols: Many EMS systems have an agitated delirium or behavioral emergency protocol. Ensure these protocols encompass drug-induced agitation, including cannabis. High-THC-concentration exposures (e.g., edibles, dabs) can cause delirium that requires the same approach as stimulant-induced delirium in terms of safety. The protocol should allow for rapid sedation if patients are a danger – intramuscular midazolam or haloperidol are typical options. Because cannabis-induced psychosis is usually not accompanied by extreme hyperthermia or acidosis (as in classic excited delirium), a benzodiazepine alone often suffices; however, each case should be judged individually. Emphasize de-escalation first, if possible, but not at the expense of safety.

5. Pediatric Ingestion Preparedness: Include specific mention of marijuana edibles in your pediatric poisoning or AMS (altered mental status) protocols. Advise crews to look for packaging or ask caregivers directly about the possibility of cannabis ingestion – sometimes parents won’t volunteer it until asked. Partner with poison control centers to keep EMS updated on trends (e.g., new THC products that look like popular candies). Additionally, stock pediatric BVMs and airway adjuncts appropriately, anticipating the need to manage small airways. Given the increase in pediatric cannabis cases, pediatric simulation drills can incorporate an edible ingestion scenario so crews practice airway management on a toddler mannequin. Reinforce that no naloxone will help here – some providers might reach for it out of habit when encountering an unresponsive child, but opioid antidotes do nothing for THC. Instead, it’s about ventilation and time.

6. Documentation and Reporting: Encourage thorough documentation of cannabis involvement. This not only protects providers (showing they considered substance effects in their differential) but also contributes to public health data. If a syndrome like CHS is suspected, document it in the impression. For instance: “Impression: Refractory vomiting, suspect Cannabinoid Hyperemesis Syndrome”. Also note patient education given (e.g., advised cessation). For pediatric cases, document which authorities were notified (poison control, CPS if applicable, law enforcement).

7. Education and Training: EMS leaders should provide ongoing education on the evolving cannabis landscape. Today’s marijuana is much more potent (20%+ THC in some strains) than decades ago, and new delivery methods (vapes, dabs, edibles) can produce novel challenges. Training should cover recognition of things like CHS, signs of edible overdose, how to differentiate cannabis psychosis from other causes, etc. Use case studies in training sessions:- For example, review the case of the 26-year-old VF arrest from cannabis as a discussion on how crews might pick up on subtle clues (the smell of marijuana or paraphernalia at scene) that could indicate a tox-related cardiac arrest.- Discuss a CHS case where multiple EMS encounters happened before diagnosis, to show the importance of pattern recognition and asking about hot shower behavior. Present a pediatric edible ingestion scenario (like the one described above) to reinforce airway management and caregiver interviewing skills.

8. Interagency Collaboration: Work with emergency departments to create a feedback loop. For instance, if EMS suspects CHS and transports, they could ask for follow-up if that was confirmed. This helps providers learn and reinforces their diagnostic acumen. Similarly, hospitals might share their increase in CHS cases or other marijuana complications with EMS agencies, prompting protocol adjustments.

9. Public Education Role: EMS often engage in public education (health fairs, school programs). Given the rise in cannabis use, EMS can collaborate with public health to educate communities about these lesser-known risks: e.g., CHS – many heavy users have never heard of it and don’t connect their vomiting to cannabis. Also, teaching parents to secure edibles and informing young users that marijuana can indeed cause heart issues could prevent emergencies. While this is ancillary to our primary mission, EMS is a trusted source of health information in many communities and can contribute to harm reduction.

Conclusion

The expansion of marijuana use in the U.S. has unveiled a range of cannabis-induced syndromes and emergencies that EMS providers must be ready to handle. From the torment of “scromiting” (cannabis hyperemesis syndrome) to acute cardiac events like arrhythmias and MIs in young users to acute psychosis or debilitating anxiety and pediatric poisonings requiring airway management – these are real and evidenced effects, not myths.

While cannabis remains a substance with legitimate medical uses and generally less acute lethality than opioids or stimulants, it is not benign. EMS personnel are on the front lines of this evolving landscape and have the opportunity to save lives and reduce harm by applying up-to-date knowledge and protocols to cannabis-related 911 calls.

In crafting protocols and training around these issues, EMS agencies should rely on emerging evidence and case studies rather than folklore. The references cited here – including peer-reviewed case reports, epidemiological studies, and toxicology reviews – provide a factual basis for understanding what marijuana can do to the body. For instance, acknowledging that haloperidol may “do the trick” where ondansetron fails for CHS or that daily cannabis use increases stroke risk by 42% or that children can end up intubated from ingesting a parent’s THC gummies., allows EMS to respond appropriately and advocate for patients.

Ultimately, the goal is to ensure EMS crews have the tools and knowledge to identify these syndromes early, provide effective prehospital care, and educate patients. A patient pulled from repetitive vomiting with IV fluids and the right medication, or a toddler whose breathing is saved with timely ventilation, or a young adult with chest pain who gets the full workup instead of being dismissed – these are tangible outcomes that robust EMS preparedness can achieve. By integrating these considerations into briefing their teams and evolving their protocols, EMS leaders will bolster their overall readiness for the unintended consequences accompanying the rise of legal marijuana use.

Sources: The information in this guide is drawn from a range of current medical literature and public health data on cannabis. Key references include StatPearls and toxicology text on CHS, case series and studies on cannabis-related cardiac arrhythmias and infarctions, psychiatric research on cannabis and psychosis, CDC reports on pediatric poisonings and emergency medicine case reports illustrating management approaches among others. By staying informed with the latest evidence, EMS can dispel outdated misconceptions and respond to cannabis emergencies with confidence and competence in this new era of widespread marijuana use.