Outbreak
Alert Update: Potential Life-Threatening Vitamin K-Dependent Antagonist Coagulopathy Associated
With Synthetic Cannabinoids Use
This COCA Clinical
Action updates the message sent on April 5, 2018: https://content.govdelivery.com/accounts/USCDC/bulletins/1e6dac3
Since the index case was
identified on March 8, 2018 in Illinois, at least 160 people have presented to Healthcare
facilities with serious unexplained bleeding. The preponderant number of
patient presentations were in Illinois with other cases being reported from Florida, Indiana, Kentucky, Maryland, Missouri, Pennsylvania, Virginia, and Wisconsin. Laboratory
investigation confirms brodifacoum exposure in at least 60 patients. There
are at least 3 fatalities. At least 7 synthetic cannabinoids product samples
related to this outbreak have tested positive for brodifacoum. At least one
synthetic cannabinoids product has tested positive for both synthetic
cannabinoid AB-FUBINACA and brodifacoum.
Lessons Learned:
Patients with a history of synthetic cannabinoids (e.g., K2, Spice, and AK47) use may:
- Present with complaints unrelated to bleeding (e.g., appendicitis) and have numerical coagulopathy.
- Be asymptomatic and ignorant of their numerical coagulopathy.
The issue with vitamin K treatment is cost, not availability. The cost of oral vitamin K for two weeks treatment can be $8,000 and treatment may be for months. Options are being explored to address these issues.
Clinical signs of
coagulopathy include bruising, nosebleeds, bleeding gums, bleeding
disproportionate to injury, vomiting blood, coughing up blood, blood in urine
or stool, excessively heavy menstrual bleeding, back or flank pain, altered
mental status, feeling faint or fainting, loss of consciousness, and collapse.
Healthcare providers should
maintain a high index of suspicion for vitamin K-dependent antagonist
coagulopathy in patients with a history of synthetic cannabinoids (e.g., K2,
Spice, and AK47) use:
- Presenting with clinical signs of coagulopathy, bleeding unrelated
to an injury, or bleeding without another explanation; some patients may not
divulge use of synthetic cannabinoids.
- Presenting with complaints unrelated to bleeding (e.g.,
appendicitis).
Healthcare providers
should be aware that patients with vitamin K-dependent antagonist coagulopathy associated
with synthetic cannabinoids use may have friends or associates who have used
the same synthetic cannabinoids product but are asymptomatic and ignorant of
their numerical coagulopathy.
All patients should be
asked about history of illicit drug use. All “high-risk” patients (e.g.,
synthetic cannabinoids users), regardless of their presentation, should be
screened for vitamin K-dependent antagonist coagulopathy by checking their
coagulation profile (e.g., international normalized ratio (INR) and prothrombin
time (PT)).
- Proceduralists (e.g., trauma/general/orthopedic/oral/OB-GYN/cosmetic
surgeons, dentists, interventional cardiologists/radiologists, and
nephrologists) should be aware that patients with a history of synthetic
cannabinoids (e.g., K2, Spice, and AK47) use may be anti-coagulated without
clinical signs of coagulopathy. These patients should be screened for vitamin
K-dependent anti-coagulant coagulopathy prior
to their procedure.
- Contact your local Poison Information Center
(1-800-222-1222) for questions on diagnostic testing and management of
these patients.
- Promptly report suspected cases to your local health
department or your state health department, if your local health
department is unavailable. In addition, report any similar cases
encountered since 01 February 2018 to your local health department.
In an effort to better
understand the scope of this outbreak, ask your Medical Examiners’ office to
report suspected cases, especially those without an alternative diagnosis. If
individuals are identified after death or at autopsy showing signs of
suspicious bleeding as described above, coroners are encouraged to report the
cases to their local health department.
For updated information
about the Illinois outbreak—connect with the Illinois Department of Health http://www.dph.illinois.gov/topics-services/prevention-wellness/medical-cannabis/synthetic-cannabinoids
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