HEALTH ALERT

FOR IMMEDIATE RELEASE                 For more information, contact:
April 20, 2018                                            Southwest District health at (208) 455-5442

SUBJECT:   Synthetic Cannabinoids-Associated Coagulopathy – Information for Idaho Clinicians

Background
On March 23, 2018, the Illinois Department of Public Health identified an unusual cluster of cases involving four individuals with severe bleeding caused by a vitamin K-dependent coagulopathy. As of April 20, Illinois has identified 146 cases, including 3 deaths. All cases were associated with using synthetic cannabinoid products before onset of severe bleeding. Similar cases have now been reported in Indiana (2), Maryland (1), Missouri (1), and Wisconsin (1).

Similar cases have not been identified in Idaho, but public health officials want to ensure clinicians are aware of these illnesses, have information about the causes, and notify public health officials of suspect cases.

Healthcare providers should maintain a high index of suspicion for vitamin K-dependent antagonist coagulopathy in patients presenting with clinical signs of coagulopathy, bleeding unrelated to an injury, or bleeding without another explanation and with a possible history of synthetic cannabinoids use; some patients might not divulge use of these drugs and should be screened for vitamin K-dependent antagonist coagulopathy by checking their coagulation profile (e.g., INR and prothrombin time (PT))

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.

If you have a patient with bleeding or an unexplained elevated INR and synthetic cannabinoid use, call the Nebraska Regional Poison Center, Idaho’s regional poison control center, at 1-800-222-1222 for clinical management and diagnostic testing information, including testing for brodifacoum.

Please contact your local public health district if cases are identified. This will alert public health officials that contaminated product could be in Idaho so that the healthcare community and public can be notified.
           
                                                Southwest District Health
                                                       (208) 455-5442
Ongoing Investigation
Testing has confirmed brodifacoum (a superwarfarin used as a rodenticide) exposure in 18 of the Illinois patients and 3 samples of synthetic cannabinoids used by patients have tested positive for brodifacoum. Unlike warfarin, superwarfarins are not approved for use in humans.

Synthetic Cannabinoids
Synthetic cannabinoids are man-made chemicals called new psychoactive substances (NPS). These are unregulated products that are either sprayed on dried, shredded plant material so they can be smoked or sold as liquids to be vaporized and inhaled in e-cigarettes or other devices. They also can be in herbal or liquid incense. Synthetic cannabinoids are also called fake weed or legal weed and have brand names such as K2, Spice, Black Mamba, Bombay Blue, Genie, and Zohai. They can be found online and in convenience stores.

Resources:
CDC outbreak Alert: https://content.govdelivery.com/accounts/USCDC/bulletins/1e6dac3
Illinois DPH Outbreak Page: http://www.dph.illinois.gov/topics-services/prevention-wellness/medical-cannabis/synthetic-cannabinoids