Highlight
- Children under 6 presenting to emergency departments with cannabis poisoning often experience delays in urine drug screen results.
- Initial complaints—neurologic, exposure-related, or both—strongly influence the likelihood of neuroimaging such as CT or MRI.
- Median time to cannabis testing results can exceed two hours, with nearly one fifth of outcomes returning after patient disposition.
- Expediting toxicology testing and encouraging early caregiver disclosure may reduce unnecessary neuroimaging and optimize resource use in pediatric emergency care.
Study Background
Cannabis poisoning has emerged as an increasing concern in young children, especially with growing legalization and accessibility of cannabis products. Accidental ingestion can lead to a range of neurologic symptoms including altered mental status, seizures, and abnormal movements, often prompting emergency department (ED) visits. Despite the clinical burden, challenges persist in the timely diagnosis and management of pediatric cannabis poisoning. Currently, urine cannabinoid drug screening often experiences notable delays, contributing to diagnostic uncertainty.
Delayed toxicology results can influence clinical decision-making practices, including the use of diagnostic neuroimaging such as computed tomography (CT) or magnetic resonance imaging (MRI). Unnecessary imaging exposes young patients to ionizing radiation or sedation risks and increases healthcare costs. Therefore, understanding the impact of toxicology screening timing and presenting complaints is essential to improve rapid diagnosis, reduce avoidable imaging, and streamline pediatric emergency care.
Study Design
This retrospective cohort study analyzed 3,653 emergency department visits from 2016 to 2024 of children younger than 6 years, all with documented cannabis poisoning diagnoses and documented urine cannabinoid tests sourced from Epic’s Cosmos database. The median patient age was 29 months, with a slight female predominance (51%) and a racial composition of 41% White.
Most encounters (80%) occurred in general emergency departments, with 20% in pediatric-specific centers. Patients were stratified into four groups based on their chief complaints documented at triage:
- Neurologic-only (n=1,540): presentations with altered mental status, seizures, abnormal movements.
- Exposure-only (n=1,203): ingestion or exposure complaints without neurologic symptoms.
- Combined neurologic-exposure (n=55): signs of both exposure and neurologic symptoms.
- Other complaints (n=450): varied presentations including trauma and screening related encounters.
Researchers characterized clinical presentations, quantified urine drug screen timing metrics, and analyzed relationships between chief complaints and neuroimaging utilization (CT/MRI).
Key Findings
Patients with cannabis poisoning generally presented as high acuity cases, with 60% triaged at Emergency Severity Index (ESI) level 2. The most frequent presentations were altered mental status (39%), ingestion or exposure history (35%), and seizures or abnormal movements (5%). Other complaints—such as trauma, screening, or alleged abuse—were infrequent.
The median time to cannabis test collection was 93 minutes, with a median result turnaround time of 152 minutes. Notably, in 19% of visits, cannabis toxicology results were obtained only after patient disposition decisions had been made, limiting their utility in acute management.
Neuroimaging was utilized in 35% of visits overall with similar rates between general and pediatric EDs (35% vs. 36%, not statistically significant). The likelihood of neuroimaging varied markedly by chief complaint group:
- Neurologic-only group had quicker median collection (72 min) and result times (132 min) and 56% received neuroimaging, serving as the reference group.
- Exposure-only group experienced longer median collection (127 min) and result times (188 min) but had significantly lower neuroimaging rates (8.8%; odds ratio [OR] 0.08, 95% confidence interval [CI] 0.06-0.10).
- Combined neurologic-exposure group showed the shortest testing times (47 min collection; 120 min result) and intermediate neuroimaging frequency (24%; OR 0.25, 95% CI 0.13-0.45).
These patterns suggest chief complaints strongly influence both diagnostic timing and imaging decisions.
Expert Commentary
The study illuminates an important operational gap in pediatric emergency care for cannabis poisoning cases. The frequent delays in urine toxicology results—often exceeding two hours—reduce their impact on acute decision-making and potentially lead to overreliance on neuroimaging as a diagnostic proxy. Neurologic symptoms understandably prompt imaging due to concerns for alternative serious intracranial pathologies; however, delayed toxicology confirmation can impede clinical confidence.
Streamlining toxicology turnaround through point-of-care testing or rapid lab protocols could empower clinicians to make more informed, timely management decisions. Additionally, fostering earlier caregiver disclosure of ingestion incidents—through caregiver education and ED triage protocols—may reduce diagnostic ambiguity. This, in turn, can limit unnecessary imaging associated risks, radiation exposure, and healthcare costs.
Limitations include reliance on retrospective administrative data and potential variability in urine test sensitivity and specificity across centers. The study’s generalizability may be constrained by institutional differences in protocols and availability of pediatric expertise.
Conclusion
Pediatric cannabis poisoning triaged in emergency departments often presents with high acuity neurologic symptoms necessitating careful evaluation. This study highlights significant delays in urine drug screen result availability, frequently occurring after key care decisions are made. Initial patient complaints heavily influence neuroimaging utilization, with neurologic presentations prompting more frequent scans.
To optimize pediatric ED care, healthcare systems should prioritize strategies to promote early caregiver disclosure, expedite cannabis toxicology testing, and critically appraise neuroimaging necessity. Addressing these gaps could reduce low-yield imaging, minimize radiation exposure, shorten length of stay, and improve resource efficiency. Future research should focus on validating rapid cannabinoid testing modalities and creating clinical pathways integrating early toxicology information into pediatric neurologic assessment workflows.
References
1. [Original study DOI: 10.1016/j.ajem.2025.08.012]
2. Wang GS, Roosevelt G, Le Lait M-C, et al. Association of Unintentional Pediatric Exposures With Decriminalization of Marijuana in the United States. Ann Emerg Med. 2020;75(2):286-293.
3. Monte AA, Zane RD, Heard KJ. The Implications of Marijuana Legalization on Pediatric Exposure in the United States. JAMA Pediatr. 2015;169(6):584-589.
4. Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4. Agency for Healthcare Research and Quality (AHRQ).
