Case 1

History

A 63 year old man was brought in by ambulance after accidental ingestion of a cannabis brownie. He accidentally ingested the brownie at 21:30. 45 minutes later he called his partner as he felt that the room was closing in on him. He then stopped interacting, so his partner called an ambulance.

Background

Hypertension

Renal calculi

No regular medications

NKDA

On Examination

He was alert but disorientated

GCS 14 - E4V4M6

He was moving all four limbs symmetrically on exam.

Speaking intermittently but with appropriate words and no slurring of speech

 

Question 1

How do you approach assessing this patient?


Question 2

What do you think is going on with them?

Question 3

What if any investigations will you request?

Question 4

What treatment will you initiate / how will you manage this patient?

Try to answer the questions before reading the next section.

 

 Introduction

Medicinal Cannabis is now legal in a number of EU countries, Australia, Canada and the majority of US states. Outside of childhood epilepsy the conditions for which medicinal cannabis is prescribed occur most commonly in older adults. This together with the fact that people born in the 1950’s and 1960’s are now entering their 60’s and 70’s leading to a more liberal attitude towards drug use among older adults, means that cannabis use among older adults has increased significantly(1).

This increased use among elderly patients presents new challenges with regard to:

  • side effect profile

  • potential increased falls

  • interaction with other medications

  • increased risk of cardiovascular complications(2),(3)

Given these challenges among the older population a very careful and thorough approach to the initial assessment and ongoing management of these patients is required.

Assessment

 

A

This patients airway was patent and protected with no noisy breathing

B

He had equal air entry and no abnormal breath sounds

His Sats were 97% on RA and RR was 17

C

This patients Hr was 84, BP was 169/82 and cap refil was normal

Ecg was normal sinus with a normal Qtc

 

D

This patient describes feeling disorientated and is responding intermittently to questions but when he does respond he is responding appropriately.

He is moving his limbs symmetrically but is too unsteady to walk independently

He has no cerebellar signs on exam and his plantars are normal

E

His temp is 36.7, cardiovascular / resp / abdo and limbs examinations are normal

His VBG shows a lactate of 3.0 and glucose of 10.7

Initial assessment above shows no serious life threatening issues. The patient is admitted for a period of observation.