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Su Ze s face showed smugness and said, Of course, and I also found two most critical problems.I immediately became interested and asked him what he found.Su Ze looked around nervously, and suddenly reached out and grabbed my hand and walked elsewhere.After leaving the place where Lu Wei and Feng Tangwei lived, he took me to the middle of the ice bridge connecting the base camp and the two islands of Linhai City.I looked at him speechlessly and said, Now just cbd gummies ingredients we can can i buy cbd gummies at circle k in phoenix talk.I turned around and grabbed the ice railing and whats the difference between hemp gummies and cbd gummies looked at the clouds below, only to hear Su Ze smiling, and immediately leaned against me and said, I found out that Shishu is not in prison.Inside, they were caught elsewhere.The uncle Su Ze referred to was Lao Huang, and I don t know why he called him that, but I didn t object and let him like Laced Cbd Gummies it.

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After the smiley tiger s signal, he calmed down, brought Xin Chen to the front again, and shouted in the loudest voice This is Xin Chen, that is, your Lord Chen, and it is the righteousness I received last night.Although the sub combat strength is only 1200 points, but the future is unlimited These words were like thunder, and they rang directly in my ear, causing my scalp to go numb, and the people below immediately became silent, even Zhang Mazi held the The teacup also stopped, and his face finally changed.Xin Chen was also stunned, apparently not reacting yet.And I didn t react, what exactly did this smiling tiger sing, and suddenly announced that Xin Chen was his adopted son.I glanced at Zhang Mazi again, and the teacup in his hand was cracked by his grip, showing how strong it was.Laughing Tiger seemed to be very satisfied with the scene, and after the people below reacted, they raised their hands and shouted Chen Ye Chen Ye Chen is a generation higher than Long brother.

I patted him on the shoulder and said, Don t think too much, we can survive, let s sleep first and wake up in the early morning.After saying that, I lay on the bed and started to fall asleep.Lao Qiu, wake up, it s almost twelve o clock.Lao Huang shook my body and called me up from my sleep.Why so fast.I got up in a daze and looked at the situation outside.At night, the dense fog was cbd gummies on amazon Laced Cbd Gummies even more invisible, but after a few minutes, the dense fog began to gradually dissipate., It was not until 12 00 that the thick fog disappeared.I immediately observed the surrounding situation carefully.It was deadly silent outside, as if no one Laced Cbd Gummies was there.Only the tree rustled when the wind was blowing, but it made the night even more terrifying.Old Huang, grab your weapons and prepare to go out.Lao Huang and I took out the machetes wrapped in newspapers under the bed, with electric batons around our waists, and carried our backpacks, ready to go out to check the situation.

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After a few hours, this surname was the only one.Qiu cbd gummies melt s and that kid came back, and Hall Master Chen didn t show up.The fourth child looked cbd gummies for anxiety kids green lotus cbd gummies at me with a sneer.Lao Huang, who was standing on the side, immediately became angry and shouted You mean they killed it and kicked the fourth child.The fourth child felt that he was not beaten enough, so he didn t speak any more, but his face became more resentful.look at me.Senior Qiu, why don t you explain Zhang Mazi s tone was unquestionable, and a murderous intent quickly spread to me, causing me to shudder.I frowned and looked at the fourth child, wondering why he was targeting me so much, but he immediately explained everything that happened last night, and even I said about Jia Yuan, Lao Huang didn t know we were here last night , I was stunned after hearing what I said.

I hugged her even harder, wishing she could melt into my arms.Because I am back, this is no longer the end of the world, and I am no longer a zombie, and there is no longer any obstacle between us to separate us.The little witch s body immediately softened, and then her arms also wrapped around my waist, put her head on my chest, and said happily, Okay, we will not be separated.We hugged After a long while, they gradually separated and then looked at each other.The little witch s face flushed crimson, as sexy as a stunner in the world.She looked at me with tenderness in her eyes, and said softly, what does a cbd gummy do What s wrong I smiled and shook my head, saying nothing.Yoyoyo, why are you doing this on the street.Lao Huang s voice suddenly sounded from behind me.The little witch and I immediately shrank our hands and let go of each other.

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child.That Zhang Jin, dressed in black, stepped over my head, stopped suddenly, turned around and attacked me with a dagger.I immediately stood up and exploded with 6,000 combat power again.Zhang Jin was at 4,000 combat power at this time, so I was immediately shocked.I frowned and looked at the childish Zhang Jin, and said solemnly, We saved you, is this how you repay us Zhang Jin s cbd gummy nutrition label face was cold at this time, as if he didn t know me.The color of his pupils didn t change, I really thought he was also controlled by Mo Xie.Lao Huang wanted to rush towards me right away, but those C level monsters blocked him with his front body.He had no choice but to attack them again.Keng Bi and Yan Yuteng were guarding at the door.The monsters are solved one by one.The Death God s side and the peninsula were fighting in full swing at this time, and it was not clear who had the upper hand for the time being.

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Helen also shot in the direction the general left.No, Wang Shuai, go find the general.I pushed Wang Shuai, but he didn t leave.Idol, if I leave, you will die.Come with me.Wang Shuai carried me and ran wildly, but Anma s speed was even faster, and he kicked Wang Shuai back all of a sudden, the two of us He fell to the ground and rolled a few times.Anma s dark face was hideous, and he clenched his fists.The sound of space rupture burst out from Laced Cbd Gummies:Do They Work?- Pathology Testing Labs Specialists In Africa his fists, and the cracks spread infinitely, and his aura suddenly rose.I just got up, and my head started to ache again.I grabbed my head and kept tapping on the ground, but adverse reaction to cbd gummies it was still useless.Ah I couldn t bear the pain in my head, and I advanced health cbd gummies rolled around on the ground and yelled.Bang Anma hit me thc free cbd gummies for anxiety from the air, and the extremely terrifying spatial shock immediately slammed into me, the ground burst open layer by layer, and dust and gravel swept the sky.

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Giggle.Wang Xinzhi still gave a weird laugh.The penetrating fangs gave off a cold light.I struggled to hold hands with him to control each other s body.He opened his mouth and bit down suddenly.After retreating ten meters, I also wiped out two broken marks on the ground.Wang Xinzhi was close to me, and immediately followed.My expression didn t change, and I calmly used Tai Chi push hands to unload his attack without any tactical confusion.And keep him at a certain distance from me, he can t attack me for a while.Although Wang Xinzhi s combat strength is 80,000 points, my current combat strength plus two state blessings is almost 80,000 points of combat strength.So he and I were evenly matched, and the two of them had been in a stalemate for a long time without a winner.Because Wang Xinzhi s attack is very crazy, he unintentionally casts deadly attacks but does not defend, I also seized many opportunities to attack him, but he seems to have no pain, just giggling and constantly attacking, which is useless at all.

Bo Ge floated down.Indifferently said You go, I will help you solve it here.I glanced at him gratefully, thanked him with a heavy head, and immediately flew away to the east.As soon as I flew out a few kilometers, I felt that the dark clouds in the sky once again enveloped the entire Linhai City, and thunder and lightning slammed into Linhai City one after another, destroying all the remaining federal parties.But my heart has not been put down, and I have been worried about the wolf wolf.If there is anything wrong with Wolf Wolf, I want the five federations to give me Wolf Wolf s life.I fired up my firepower and rushed again.I immediately felt four auras in the air, and three of them were more powerful.They were at the level Laced Cbd Gummies of a Laced Cbd Gummies best cbd gummies for joint pain four star hunter The other aura was sluggish, it thc cbd cbg gummies was negative effects of cbd gummies Ax, and it was accompanied by a faint what does cbd gummies do Laced Cbd Gummies aura.

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Brother Bo stood next to me and smiled and said, You have a long time to live.I smiled bitterly and said, I feel like I m about to die, and there is not much time left.Brother Bo asked me, then Why are you still here I looked at the direction Qiu Sheng left and said, I wanted to come back to stop him, but I couldn t stop him, so I could only watch him do something regretful again.Not long after, I saw Qiu Sheng in the Bermuda Triangle being swallowed into a time space misappearance, and I knew that it was time for me to appear again.As soon as Qiu Sheng disappeared, I immediately appeared in Bermuda, and God saw my eyes full of puzzlement.I didn t say a word, I directly attacked with all my strength.The terrifying aura instantly made Tu Wenxuan flee, and Zhou Jiahe didn t see me and was immediately stunned.

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Planted this time.I quietly opened the infinite space in my body, pulling the combat power to heal.I looked at the Xin Chen standing in front of me and sneered at me, and said, You are not Xin Chen, he will not call me Brother Wolf.Who are you Xin Chen How s it going That Xin Chen suddenly spread his hands and pretended to be sad I didn t expect you to forget me so soon, but don t worry, my godson isn t dead yet.Could it be me The distress suddenly accelerated, looking at the Xin Chen in front of him, he couldn t help but be surprised You are Brother Tiger Xin Chen snorted coldly, and immediately a blood color spread down from the top of his head, and the skin gradually turned up Variety.In best cbd gummies at gas station the end it turned into a smiling tiger.Madd, it was him.Laughing Tiger looked at me and said, If it wasn t for the abominable A rank zombie that ruined my business last time, I would have already become the owner of the Ghost Gate Village.

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Because Huaxia has no pillar industries of its own at all, the https://greenlotushemp.com/ biggest benefit of the lord s mansion is only the taxation of agriculture. Just now they watched the performance of the first batch of magicians, and they were so excited. The Potter family actually betrayed the kingdom, benefits of cbd you should immediately send someone to arrest him and inform His Majesty the King. The right phase looked at the departing back, and there was laced cbd gummies a hint of ruthlessness in his eyes.

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Just as he would challenge Darren and Barron if he had enough power, He stood up with a chuckle: laced cbd gummies Of course you want to be laced cbd gummies in the ring, I don t think you will give me this position directly. Mickey has agreed that the Guardian of Light will notify the three kingdoms of the cooperation with Tianmu, and let the three kingdoms inform the whole country. I don t know what the three adults are coming here this time? We have some things to discuss with Tianmu, which may disturb the lord for a few days. If Lieyang Kingdom used these two giant dragons to throw boulders to laced cbd gummies attack ordinary soldiers, how many would they kill at one time? It would take at least a few minutes for them to fly back and forth, and even if they laced cbd gummies hit them for a day, it wouldn t cause much damage. Even if this shadow is wonderful cbd pills not at the level of the snack merchant, his strength must be above the peak 8 gummies of ordinary legends. After that, he didn t give Galen and others a chance to laced cbd gummies complain again, and left quickly.

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Choose the lottery, fortunately, this time the pointer did not select the small wooden laced cbd gummies box, but stopped on the scroll. The huge beam of light that suddenly appeared made the entire battlefield stunned. His face sank: If you want to take it, you can take it, this is an order. There are such smart people in the world? Weed grass can t believe it, He has been learning magic technology from the village chief since he was a child. Hearing the words, Galen and the laced cbd gummies others stepped back where can i buy harlequin cbd oil and looked at Mars opposite with a smile. It is absolutely a shame for cbd gummies for pain the kingdom to hand over Benedict, How long can the peace bought from the sale of dignity last. At the same time, in the high-end battle, Rutgers was injured by cbd store near me Carus, and the city lord s mansion was forced to give up the best cbd products best store thc gummies pursuit, saying Perhaps the City Lord s Mansion can achieve even more brilliant results. The shopping guide girl followed the stairs and went straight to the seventh floor. In the underground world, above the bloody legion, a space crack appeared out of thin air.

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He thought that these lords would be dissatisfied with the long-awaited arrival, but he did not expect this to be the case now. Riven independently, If the hero is successfully selected, the summoning will cost 150,000 gold coins.

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Blanche didn t want to stand here with Chesterton talking nonsense, she nodded and jumped back to distance herself from Chesterton. Once a member all natural cbd cream of the Shadow Eagle appears in Nice There is no amnesty in the city area! In this way, the Nice city area may be the most unlikely place for Shadow Eagle members to appear, and it is even safer than the king s capital.

It is impossible for us to mobilize such a large-scale force, Know, Moreover, compared with the strength of the Blue Shirt Army and our City Lord s Mansion today, the Blue Shirt Army has to deal with us and lead troops to attack directly, so why bother. After it is turned on, lloyds pharmacy cbd sleep gummies the time flow rate is doubled, and the lifespan of the creatures in the performance field is not affected by the time acceleration.

If you don t want to die, don t say anything, The boss stood behind the guard and said softly. It is his duty to make plans, and it is up to him to decide whether to adopt them or not. Light and shadow cbd gummies near me flashed, and Galen s image began to change, The original blue and gold-edged battle armor turned into a metallic edible gummies blue-black, and the breastplate cbd oil biotech 1000mg best results cbd store and hem were blood-red bright red. After the reception, he also invited a few nobles who could talk extra strength cbd oil dr phil to him or who had higher froggys cbd gummies titles to watch the performance with him on the main stage on the day of the celebration. They used to cbd for anxiety be a childhood sweetheart couple, but your grandson wanted to take love with a knife. The boss knew that if he wanted to get news of Swain, he had to go to Saint Zeil City.

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A Case of Toxicity from Cannabidiol Gummy Ingestion

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

A 56-year-old male with no known history of substance abuse and no known prior medical conditions presented via ambulance to the emergency department after being found by coworkers with bizarre behavior, vomiting, and slurred speech. He had legally purchased cannabidiol (CBD) gummies marketed for pain and anxiety relief at a gas station several hours prior. Vitals upon arrival were temperature 36.8 Celsius, heart rate (HR) 79, respiratory rate (RR) 12, blood pressure (BP) 113/60, and oxygen saturation (O2) of 84% on room air that improved upon arousal. Physical exam showed an obese man in no acute distress with a depressed level of consciousness but who awoke to painful stimuli. Neuro exam was significant for dysarthric, hypophonic speech. Labs were significant for a primary respiratory acidosis with concomitant mild lactic acid elevation, normal bicarbonate, and normal anion gap. A comprehensive urine toxicology screen including cannabis was negative. Vital signs three hours after presentation deteriorated, showing: HR 47, RR 8-12, BP 88/52, O2 78%. Electrocardiogram (EKG) revealed sinus bradycardia. The patient progressively became more obtunded and required constant stimuli in order to maintain a patent airway. Non-invasive positive pressure ventilation was not administered due to persistent emesis.

The patient underwent supportive care with intravenous fluids, oxygen, anti-emetics, continuous stimulation, and close neurologic monitoring with full recovery by the following morning. Further, patient history revealed that he had consumed two packages of CBD gummies, totaling 370 mg total of CBD (serving size on the package was 30 mg). He felt the products were healthy and safe based on packaging and therefore did not believe they would have any adverse effects.

CBD is one of many cannabinoids found in marijuana and marijuana-derived products. It is generally considered safe unlike its more psychoactive counterpart, tetrahydrocannabinol (THC), which has been linked to seizures, respiratory depression, and cardiovascular complications. CBD has surged in popularity recently, being marketed in oils, capsules, and candies as a health supplement, claiming to treat a wide variety of medical conditions such as glaucoma, pain, and even having beneficial effects on cancer prevention. Most currently available studies do not look at isolated CBD nor their synthetic equivalents, and purity is not guaranteed, thus leading to unforeseen side effects and toxicities. Moreover, these compounds do not show on traditional toxicology screens, posing a diagnostic dilemma for physicians. This case of respiratory depression and cardiovascular compromise in a relatively healthy man is just one example of the importance of considering synthetic CBD toxicity in the differential diagnosis, as there is little data available for recognizing and treating this condition.

Introduction

Cannabidiol (CBD) is a rising trend in pop-culture. It can now be found in baked goods and candies, infused into coffees, and on the shelves of stores in cosmetics and oils. Benefits have been found for specific seizure disorders such as Lennox-Gastaut syndrome and Dravet syndrome; it is also being studied for its role in neuropathic pain [1-2]. The excitement over these treatments has spurred the production of a multitude of CBD-containing products that advertise a broad spectrum of clinical benefits such as improving arthritis-related pain, potential curative effects on cancers, to an overall improvement in well-being. While these claims are unfounded, the general consensus from the World Health Organization is that CBD is well-tolerated with a good safety profile [3]. This is a case report of a 56-year-old male who experienced significant neurologic, cardiovascular, and respiratory depression due to CBD product intoxication.

Case presentation

A 56-year-old male on no medications with no known history of substance abuse presented via ambulance to the emergency department after being found by coworkers with bizarre behavior, vomiting, and slurred speech. He had legally purchased “CBD gummies” marketed for pain and anxiety relief three hours prior to his presenting to the emergency department, hoping they would help relieve pain from a recent back injury (Figures ​ (Figures1, 1 , ​ ,2 2 ).

Bag of CBD gummies consumed by patient marketed as a healthy solution for pain relief. Per packaging, each gummy contained 15 mg CBD.

A second bag of CBD Gummies consumed by the patient and scanned into the chart upon arrival. Product reportedly contained 50 mg CBD, 44 mg B12, and 400 IU D3 per gummy.

Upon arrival, vital signs (VS) were significant for hypoxia which did improve upon arousal. [Table ​ [Table1 1 ]

Table 1

Initial Vital Signs
Temperature 36.8 degrees Celsius
Heart Rate 78 beats per minute
Respiratory Rate 12 breaths per minute
Blood Pressure 113/60
Oxygen Saturation 84% on room air

Physical exam showed an obese male in no acute distress with a depressed level of consciousness, but who awoke to painful stimuli. Neuro exam was significant for dysarthric, hypophonic speech. He was also noted to have non-bilious, non-bloody emesis intermittently. Arterial blood gas at that time showed a mild acute respiratory acidosis with normal anion gap, normal bicarbonate, and a mild lactic acid elevation (Table ​ (Table2 2 ).

Table 2

Arterial Blood Gas
pH 7.30
pCO2 50.4
pO2 83.3
Lactic Acid 2.4

Labs were obtained and were notable for leukocytosis and mildly elevated creatinine kinase (CK) and CKMB (Table ​ (Table3). 3 ). A comprehensive toxicology screen including cannabis was negative (Table ​ (Table4 4 ).

Table 3

WBC, white blood cell count; RBC, red blood cell count; Hb, hemoglobin; Hct: hematocrit; Na: sodium; K: potassium; Cl, chloride; CO2, bicarbonate; CK, creatinine kinase; CKMB, creatinine kinase-MB

(H) indicates an elevated level, (L) indicates a low level

Initial Laboratory Values
WBC (H) 17.8
RBC 4.65
Hb 14
Hct (L) 41.7
Platelets 208
Na 139
K 4.5
Cl 107
CO2 25
Anion Gap 7
CK (H) 341
Ca (L) 8.4
Serum Alcohol
Troponin
CKMB (H) 4.4

Table 4

AMPX, amphetamines; BAR20: barbiturates; BEN, benzodiazepines; CAN 50, cannabinoids; OPI, opioids; PCP, phencyclidine; COC, cocaine; METH, methamphetamine

Urine Drug Screen
AMPX Negative
BAR200 Negative
BEN Negative
CAN 50 Negative
OPI Negative
PCP Negative
COC Negative
METH Negative

He was admitted to the medical floor, and VS 3 hours after presentation deteriorated, showing bradycardia with a nadir HR of 47, bradypnea as low as 8, blood pressure of 88/52 mmHg, and oxygen saturation as low as 78%. EKG revealed sinus bradycardia (Figure ​ (Figure3). 3 ). Narcan was given multiple times without improvement. The patient progressively became more obtunded but was able to maintain a patent airway with intermittent, aggressive stimuli. He was transferred to the intensive care unit (ICU) for close monitoring and possible intubation. Non-invasive positive pressure ventilation was not administered due to continued emesis.

The patient underwent supportive care with intravenous fluids, anti-emetics, oxygen via nasal cannula, and continuous aggressive stimuli. The following day, 18 hours after admission, the patient was fully alert, oriented, and VS showed signs of improvement (Figures ​ (Figures4 4 – ​ -6). 6 ). The patient recalled consuming 2 entire packages of CBD gummies, totaling 370 mg of CBD (serving size on the package was 30mg). He felt the products were safe based on packaging and ate them as he would eat any other candy, not believing they would have any adverse effects.

Significant bradycardia observed at approximately 3 hours after initial presentation with spontaneous recovery at approximately 26 hours.

Patient became hypotensive almost immediately after presentation which remained persistent until spontaneous recovery began to be seen at approximately 17 hours post-presentation with full recovery seen by the 26-hour period.

Upon presentation, the patient demonstrated some bradypnea which became more pronounced and persistent in the 9-21 hours after initial presentation. Again, spontaneous recovery occurred at approximately the 26-hour mark.

Discussion

This patient suffered neurologic and cardiopulmonary depression as a result of acute CBD intoxication. He was in his usual state of health prior to consuming two packs of CBD gummies. His heart rate, respiratory rate, and blood pressure dropped abruptly shortly after presentation and then experienced spontaneous recovery around 18-26 hours later without any intervention other than supportive care. This pattern of onset and recovery is consistent with toxin ingestion presumably from the CBD gummies which was the only known variable compared with the patient’s typical routine. Due to the report given by his coworkers, it was initially suspected that CBD overdose was the cause for this intoxication, of which there are no known published cases. However, given the lack of regulation and heterogeneity of over-the-counter CBD products, it is unclear which substance or substances were to blame in this patient. Similar cases are likely to be seen as these products become more commercially available.

One such case published in the literature is that of a 9-year-old boy with history of medically refractory epilepsy, diabetes insipidus, hypothyroidism, hemiplegic cerebral palsy, arachnoid cyst resection, and hypothalamic hamartoma resection who experienced profound neurologic and respiratory depression after CBD oil ingestion. The patient was being administered 1 drop of CBD oil to the gums daily but had incidental ingestion of 5 mL on the day of presentation. Upon arrival to the emergency department, he was noted to by hypothermic with depressed mental status and Glasgow coma score of 4-5 as well as decreased respiratory drive, leading to intubation. Urine screening was notable for a metabolite of THC, but testing was not readily available for CBD nor for synthetic cannabinoids. Mass spectrometry analysis of samples of the CBD oil from the same batch showed differing amounts of both CBD and THC. While the patient recovered, the exact constituent which caused the clinical findings mentioned was not able to be established due to lack of consistent formulations, purity, and potency of the commercially available products [4].

When comparing the two cases, there are certain similarities and differences which are worth mentioning. The pediatric patient consumed CBD oil, whereas the 56-year-old man ingested CBD gummies. In both scenarios, more of the CBD-labeled product was consumed than was recommended, and both patients required short-term hospitalization. In the case of the pediatric patient, testing for urine THC metabolites was also available. Neither patient had access to point-of-care testing for CBD or synthetic cannabinoids.

The CBD industry is projected to reach sales of $23 billion by 2023 [5]. This surge is likely due to the excitement behind potentially new medical breakthroughs and the desire as a culture to shift towards therapies that are more “natural.” However, most products, such as the one purchased by this patient are unregulated. Products can contain varying amounts of CBD in addition to unstudied cannabinoids, THC, or toxins such as pesticides and heavy metals. A recent study found that only 31% of 84 CBD products sold online from 31 companies were labeled correctly regarding the concentration of CBD. Additionally, THC was found in 21% of samples among other cannabinoids [6].

With the lack of a known blood level at which CBD exhibits toxic effects and the possible contamination of the product with other cannabinoids and toxins, it is difficult to know whether this is a true CBD intoxication versus toxicity from one of the constituents found in the product. Contributing to this diagnostic dilemma is the fact that the majority of these products are synthetic which allows for a larger spectrum of cannabinoids and much higher concentrations than would be found in natural sources. Additionally, synthetic products do not appear on standard toxicology screening, as was the case in this patient [7] (Oral Presentation: Bass, DO, Jessica, Linz, MD, David. Hashing Out the Unknowns of the CBD Craze. 2019 SGIM Annual Meeting; 5/11/2019).

Conclusions

This is a case of profound neurologic, cardiac, and respiratory depression secondary to acute CBD product intoxication resulting in ICU admission. The patient’s lack of substance abuse history and unintentional overdose should raise concern for physicians as more people are consuming such products. The aggressive marketing of these products paired with the lack of regulation and quality control has the potential to cause a significant negative impact on public health. Clinicians should be aware of this when prompted for advice from patients as well as when treating patients with potential intoxication. Further research into these compounds is certainly indicated and regulation may be warranted for consumer protection.

Notes

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