Cannabis Intoxication

Cannabis contains Delta-9 Tetrahydrocannabinol (Δ-9-THC) and Cannabidiol (CBD). The psychoactive properties of cannabis are typically attributed to Δ-9-THC, which is present in variable concentrations dependent on the strain and absorbed at variable rates dependent on the route of exposure. Acute intoxication is rare from CBD products unless given in excess or with high THC:CBD ratio. Canadian legalization of cannabis has been associated with an increased rate of hospitalization for cannabis exposures in children 14 years and younger.¹

UNINTENTIONAL INGESTION (PREDOMINANTLY TODDLERS)

• Consider in any previously healthy afebrile child <12 years with acute onset of the following symptoms without another clear cause:²
  • Lethargy, coma
  • Tachycardia, hypoventilation/apnea (5% of children will need intubation), bradycardia, hypotension, hypothermia
  • Hypotonia, ataxia, hyperactivity/irritability, hypertonia, tremor, seizures (CBD alone has some anticonvulsant activity, but in overdose can cause seizures)
  • Delayed recognition of cannabis intoxication results in increased testing/interventions and longer Emergency Department length of stay.

INTENTIONAL AND/OR CHRONIC USE (PREDOMINANTLY ADOLESCENTS)

• Common presentations after high doses include delirium, panic attacks, anxiety, psychosis, myoclonic jerking, nausea, vomiting, hypertension and/or worsening asthma symptoms.
• For more information regarding vomiting associated with chronic use, refer to TREKK’s Cannabinoid Hyperemesis Syndrome Bottom Line Recommendations.

INGESTION

• High concentration edible products are commercially available or can be made at home, making the dose difficult to determine reliably. Legal commercially available edibles are required to state the dose of THC and/or CBD per unit/total package.
• Edibles are more easily accessible to young children who can ingest large doses unintentionally, potentially leading to altered LOC and respiratory depression. Edible ingestion is a strong predictor of ICU admissions in the pediatric population.³
• Pharmaceutical cannabinoids, including nabilone and dronabinol (tablets) or Sativex® (rapid acting oral spray of THC and CBD), have similar time to peak effects as edibles.

INHALATION

• Inhaled dose depends on depth of inhalation and duration of puffing/breath holding. Alternative methods of inhalation of highly concentrated cannabis (e.g., vaporizing, dabbing), can lead to very rapid effects.
• Synthetic cannabinoids (e.g., “Spice”, “K2”) have similar symptoms of intoxication but are associated with more CNS depression/agitation and potentially life-threatening symptoms (e.g., seizures, respiratory depression).

• Perform work up for other causes of altered LOC if no clear history for cannabis intoxication is provided.
• With altered LOC, strongly consider: POCT glucose, venous blood gas, lactate and electrolytes. Consider CBC, liver enzymes, blood cultures, ECG and/or intracranial imaging, as required.
• CAUTION: Urine drug screen for the urine metabolite of Δ-9-THC can remain positive for weeks and does not necessarily reflect acute intoxication or rule out other possible co-ingestions/causes for altered LOC. There is a risk of false positives. Results rarely change clinical management.
• In order to assess for co-ingestions, ask patient/family what medications are in the home/accessible and check serum levels when possible (e.g., acetaminophen, salicylates).

• Consult Poison Control/Toxicology and/or Pediatric Referral Center early, especially with major derangements in neurologic or respiratory status.
• Consider activated charcoal with appropriate timing of presentation and clinical circumstance.

• Transfer to Pediatric Referral Centre/admit to hospital if persistent altered LOC or intractable vomiting.
• If asymptomatic 6 hours post-exposure, patient may be discharged home.
• If intentional exposure by a guardian is suspected, discuss case with Child Protection Specialist at Pediatric Referral Centre and report to Child Welfare Authority.

• With the exception of CBD for specific seizure disorders, there are very few proven indications for medical cannabis use in children and many concerns for acute and long-term risks.
• Provide parental education on the dangers of cannabis in children and safe storage of dangerous medication and substances. For more information for parents, visit: Caring for Kids – Cannabis: what parents need to know.
• Use harm reduction strategies to counsel teens regarding cannabis use and refer to local resources and services due to long-term concerns for their mental health (increased risk for psychosis), attention, concentration, memory and executive functioning.

Thank you to the following content experts who led the development of the Cannabis Intoxication and Cannabinoid Hyperemesis Syndrome Bottom Line Recommendations and Cannabis Supplement Table:

Kaitlin Hogue, MD, Resident – Pediatric Emergency Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Health Sciences Centre Children’s Hospital of Winnipeg

Neil Desai, MD, Clinical Assistant Professor, Division of Emergency Medicine, Department of Pediatrics, Faculty of Medicine, University of British Columbia

Thank you to the TREKK Editorial Committee, Editor Dr. Sarah Reid (CHEO), and CHRIM Parent and Youth Advisory Committee who provided editorial support and expertise in the development of this resource. Thank you as well to Mateja Carevic, TREKK Project Coordinator (University of Manitoba) who coordinated the development process.

To see our resource development process please visit our website here.

• Auger N, Luu TM, Ayoub A, Bilodeau-Bertrand M, Lo E, Low N. Cannabis-related Hospitalizations Among Youth in Canada Before and After Cannabis Legalization. J Addict Med. 2020;10.1097.
• Richards JR, Smith NE, & Moulin AK. Unintentional Cannabis Ingestion in Children: A Systematic Review. J Pediatr. 2017;190, 142-152.
• Cohen N, Galvis Blanco L, Davis A, Kahane A, Mathew M, Schuh S, Kestenbom I, Test G, Pasternak Y, Verstegen RHJ, Jung B, Maguire B, Rached d’Astous S, Rumantir M, Finkelstein Y. Pediatric cannabis intoxication trends in the pre and post-legalization era. Clin Toxicol (Phila). 2022 Jan;60(1):53-58. doi: 10.1080/15563650.2021.1939881. Epub 2021 Jun 17. PMID: 34137352.
• Government of Canada. Packaging and Labelling Guide for Cannabis Products. Published December 9, 2019. Accessed September 5, 2020.
• Vo KT. et al. Cannabis Intoxication Case Series: The Dangers of Edibles Containing Tetrahydrocannabinol. Ann Emerg Med. 2018;71(3), 306-313.
• Sorensen CJ, DeSanto K, Borgelt L, Phillips KT, Monte AA. Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment-a Systematic Review. J Med Toxicol. 2017;13(1):71-87.
• Claudet et al., Marie-Jeanne Study Group for the M.J. S. Unintentional Cannabis Intoxication in Toddlers. Pediatrics. 2017;140(3), e20170017.
• Heizer JW, Borgelt LM, Bashqoy F, Wang GS, Reiter PD. Marijuana Misadventures in Children: Exploration of a Dose-Response Relationship and Summary of Clinical Effects and Outcomes. Pediatr Emerg Care. 2018;34(7):457-462.
• Noble MJ, Hedberg K, Hendrickson RG. Acute cannabis toxicity. Clin Toxicol (Phila). 2019;57(8),735-742
• 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. Ann Emerg Med. 2020 Nov 5:S0196-0644(20)30666-1.

For a complete list of the evidence that informed the creation of the Cannabis Intoxication Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use