Symptomatic sinus arrest induced by acute marijuana use
Marijuana is considered a drug of low-toxicity, however its chronic and excessive use is regarded as a risk factor for general and cardiovascular health. Although investigated for therapeutic benefits, it can evoke electrocardiographic abnormalities in a dose-dependent manner. We report a case of a 54-year-old female who presented to the emergency department (ED) experiencing intermittent episodes of presyncope with tingling sensations around the left-side of the mouth and arm following acute inhalation of marijuana. Documented episodes of sinus arrest were noted.
A 54-year-old female presented to the emergency department (ED) after episodes of decreased levels of consciousness following acute marijuana use. The intermittent episodes were presyncopal, where the patient felt frequent dizziness with tingling sensations around the left-side of the mouth, as well as in the left arm with chest pressure and lightheadedness for 2 hours. The past medical history was significant for frontotemporal craniotomy for brain aneurysm, cerebrovascular accident, and chronic obstructive pulmonary disease. There was no previous history of coronary artery disease, myocardial infarction, angina, palpitations, or chest pain. The patient was receiving antidepressants, bronchodilators, narcotics, and anti-inflammatory agents, all without changes prior to this indexed episode.
The patient was a regular cigarette (1 pack/day) and marijuana (3 g/day-joint) smoker. On this particular occasion, she reportedly smoked 1 g of marijuana and noted the aforementioned symptoms for the first time. While in the ED, the initial heart rate varied between 70–103 beats per minute (bpm) under sinus rhythm. Shortly after, she was witnessed to have an episode of sinus arrest with a 4.6 s pause where the heart rate dropped to 38 bpm ( Figure 1A ). After a few beats, another prolonged asystole was observed ( Figure 1B ). Sinus rhythm resumed several hours after admission and her symptoms self-resolved ( Figure 2 ). Upon physical examination, the patient had normal heart sounds and no significant murmurs. Her blood pressure was 118/70 mmHg, O2 saturation of 92% and a temperature of 36.4 °C. The echocardiogram was normal. Upon follow-up of whether a pacemaker was warranted, the patient was non-compliant and did not return.
Rhythm strip. (A) A rhythm strip demonstrating an episode of sinus arrest after marijuana use; (B) another repeated episode of prolonged asystole after a few beats.
An electrocardiogram obtained a few hours after admission demonstrating normal sinus rhythm with normal PR, QRS and QT intervals.
ECG description and discussion
The rhythm strips on admission ( Figure 1 ) demonstrate sinus arrest resulting hours after consumption of 1 g of marijuana in a patient with no previous cardiac history. This likely represents a sudden increase in vagal tone and parasympathetic activity due to marijuana consumption (1). It has been shown experimentally that marijuana can induce severe postural dizziness and syncope in a small randomized study with healthy subjects. Subjects who experienced severe dizziness stood upright after drug intake, and a drop in pulse-rate, middle cerebral artery blood-velocity, and blood pressure was observed (2). Recently there has been a steady increase in case reports describing asystolic events shortly following marijuana usage. Menahem reported sinus arrest with 17 pauses and 2 syncopal episodes in a 21-year-old male who had consumed 25–35 “bongs” of 1 g marijuana mixed with tobacco. The previous history was significant for congenital heart disease and cardiac surgery (3). Brancheau et al. linked marijuana use to sinus arrest and recurrent syncope in a 28-year-old healthy male with no previous cardiac history, although the amount of marijuana consumed was not reported (1). These cases document young male patients experiencing asystolic episodes followed by syncope. Our case adds to the growing literature and demonstrates an example of sinus pauses most likely induced by marijuana intake in a female with no previous cardiac history. In our case, the patient did not lose complete consciousness, and this could be due to the patient being seated or reclined.
As no toxic screening, serum or urine tests were performed, an ideal causal relationship cannot be established, however since the sinus arrest and presyncopal symptoms shortly succeeded marijuana inhalation, a presumptive cause-and-effect relationship was inferred. Our case, in conjunction with previous literature, may allow clinicians to stay vigilant in recognizing the electrocardiographic pathologies in the context of marijuana use as a sinus arrest during extreme increases in parasympathetic activity may precede a cardiac arrest.
Points to ponder
Marijuana use has been linked to serious adverse outcomes. The main psychoactive component of marijuana is Δ 9 -tetrahydrocannabinol (THC), which mediates its effects by interacting with two G-protein-coupled cannabinoid specific receptors—CB1 and CB2. The CB1 receptor is most abundantly expressed in the brain, whereas CB2 is normally present in the cells of the immune system (4,5). Marijuana is postulated to affect the autonomic nervous system in a dose-dependent manner, where a low-to-moderate intake induced tachycardia and raised blood pressure via sympathetic stimulation, whereas a high dose is linked to hypotension and bradycardia through a predominant increase in parasympathetic activity (5). It can also produce more serious, life-threatening, ventricular arrhythmias (6). Due to the aforementioned findings, cannabis smokers presenting with symptoms such as syncope and presyncope should be offered monitoring.
What Causes Sinus Pressure
Pressure within the sinuses occurs when the membranes of the nasal passages experience inflammation or swelling. Examples of causes behind sinus pressure include sinusitis, irritants within the environment, and the accumulation of mucus from illnesses, such as allergies and the common cold.
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The sinuses are very small, hollowed-out spaces that are located within the head. Issues with the sinuses may prove to be very uncomfortable. Pressure is often experienced in the forehead, around the eyes, in the cheeks, and may even be felt in the teeth.
Why Do I Get Sinus Pressure?
Sinus pressure is a direct result of blocked nasal passages. When the sinus cavity is unable to properly drain, inflammation and pain will typically develop. Most individuals suffer from this pressure as a result of allergies and colds.
Where Are the Sinus Cavities?
Each sinus cavity is a hollow space that is full of air. They are located behind the eyebrows in the forehead, inside the bony structures of the cheek area, right in front of the brain behind where the nose is located, and on each side of the bridge of the nose.
Is it Possible to Have Sinus Pressure and No Congestion?
Yes, it is possible to experience pressure in the sinus cavity, but not have any congestion. This is most common with people who have had sinus issues or bouts of allergies in the past.
How Long Does Sinus Pressure Last?
The amount of time that pressure in the sinuses lasts depends on the underlying cause. For example, if you experience sinusitis, you could experience symptoms for up to a month. If you have allergies, it could last for several weeks. If it stems from a common cold, the pressure most often lasts about two weeks.
Why Do I Feel Weird When I Have Sinus Pressure?
If you experience sinus pressure that stems from allergies, the mast cells (or histamines) will result in a foggy feeling. These cells are known for detrimentally impacting a person’s level of cognitive clarity.
Furthermore, the air that you are taking in is not being properly filtered by the body, which results in compromised breathing. This – in turn – causes the body to experience a lack of oxygen.
Additionally, any lack of sleep you may be experiencing, any infection in which you are suffering, and the medications that you take for your symptoms may all result in a mysterious type of brain fog.
What is Sinusitis?
Sinusitis is an inflammation that occurs within the sinuses. There is acute sinusitis, which is temporary and goes away within 3 – 8 weeks. Then, there is chronic sinusitis, which last longer than 8 weeks or occurs more than 3 months at various times throughout the year.
This requires treatment.
Many medical doctors will identify sinusitis as a type of infection.
It has been established that sinusitis is one of the most common medical issues and currently impacts the lives of approximately 31 million people, in the United States alone.
What Causes Chronic Sinusitis?
Chronic sinusitis is most commonly a direct result of a bacterial-based infection. In some instances, viruses and fungi may cause the infection. If you have a weakened immune system, you are more likely to experience consistent bouts of sinusitis.
The inflammation that occurs with this medical condition may cause the following to occur among sufferers:
- Many will experience an increased production of fluid within the sinus cavities, which has the potential to lead to higher levels of swelling.
- The sinuses will not be able to drain the excess fluid and congestion in the nasal cavities will occur.
- When the drainage reduces or is stopped, pressure may build in the sinus cavities to the point where a sinus headache may develop. These have the potential to be quite severe.
What Are the Most Common Causes of Sinusitis?
There are numerous reasons why sinusitis may develop; however, the following outlines the most common causes of the medical condition:
- Allergies to pollen, chemicals and other substances are known to cause sinusitis.
- Hay fever is a common cause behind inflammation of the nasal passages.
- Infections located within the nose, the windpipe, and/or the lungs due to bacteria or viruses is a common culprit of sinusitis.
- Tissue growths (polyps) that grow inside of the nose make it very difficult to breathe from the nose due to the fact that they block the sinuses.
- If there is an uneven wall of tissue between the nostrils (deviated septum), the flow of air may be limited and result in the development of sinusitis.
Is Sinusitis a Permanent Condition?
It is possible for sinusitis to develop permanent chronic sinusitis. It all depends on the underlying cause of the condition. If you suffer from chronic sinusitis, there are many treatments that may prove to be effective. These include decongestants, oral corticosteroids, antibiotics, physical therapy, and more!
What Are the Best Treatments for Sinus Pressure?
Once the underlying cause of the sinus pressure you are experiencing has been determined, the following treatments may prove to be very helpful in overcoming the symptoms and possibly even the condition – as a whole:
- Intranasal Corticosteroids
- Oral Corticosteroids
- Saline Irrigation
- Physical Therapy
- Balloon Sinuplasty
- Functional Endoscopic Sinus Surgery
- Warm Compresses
- Increased Fluid Intake
- Neti Pot
- Allergy Medications
- Moist Air Exposure
How Does Physical Therapy Help with Sinus Pressure?
There are several strategies used by physical therapists to help people who suffer from sinus pressure. The following outlines these techniques:
- Suboccipital Release – This is a release that is performed of the head in the area of the base of the neck. This helps stretch the body from the head all the way to the tailbone area. It helps in the redistribution of sinus cavity fluid throughout the rest of the body. It is not a painful procedure. In fact, many claim that having this procedure performed not only helps in opening up the sinuses and alleviating pressure, but also helps in reducing pain and pressure in other areas of the body.
- Neck Muscle Stretches– When the physical therapist works to stretch the neck muscles, it helps increase the circulation to all of the tissues and actually relaxes the neck. This is very helpful if you have neck pain too. The increased circulation provides additional nutrients to the glands associated with the sinuses that are swollen and experiencing irritation. In addition to the stretches, the physical therapist may have the sufferer perform other exercises that are known to be beneficial to the neck and upper back region of the body.
- Sinus Release – This physical therapy technique uses taps and/or strokes directly to the sinus cavities situated within the forehead. Not only does this help alleviate pressure, it helps in the drainage of any fluids within the sinuses. It uses a little pressure, but it is necessary to initiate the process of draining the fluid from the sinus cavities throughout the face, forehead, and cheek area.
- Electrical Stimulation – Physical therapists can use a special machine called an “accelerated recovery performance machine” to provide electrical stimulation to the sinuses. This encourages the cavities to open up, which helps in the drainage of the fluid contained therein. Many prefer this because it gets rid of the congestion and allows for easier breathing. This is not a painful procedure. It may result in a little tingling, but nothing compared to the pressure that is occurring within the sinuses.
- Kinesio Tape – This specially-designed tape is typically applied to the back side of the neck. It works by reducing inflammation and alleviating pain in the area of placement. Many physical therapists may elect to use small pieces on the forehead and/or around the bridge of the nose. It all depends on the comfort level of the patient.
- There are many different exercises and stretches that a physical therapist may help you with that will help in optimizing your posture, reducing the amount of muscle tension that you experience, and improve the overall mobility of your jaw – all of which can assist in opening up the sinuses and helping you breathe more comfortably.
We here at Back to Motion Physical Therapy offer many tools, services, and programs that have proven to be highly effective treatments for individuals who suffer from sinus pressure.
Our goal is to address the soft tissues that are causing your pain and discomfort.
We will also evaluate other areas of the body that could have a detrimental effect on your body, such as the neck, the upper back, and the circulation. We specialize in manual therapy, massage, dry needling, posture retaining exercises, and more.
The services that we offer include balance training, vestibular therapy, smart fit, the antigravity treadmill, and more! Regardless of your needs, we can assist you! We offer a one-stop shop for all of your health care needs. Our therapists have extensive training in all aspects of the body. If you would like to learn more or want to set up an appointment, contact us today.