A 41‐year‐old male was brought into the emergency department (ED) with a self‐inflicted stab wound. Two days prior to admission, the patient had consumed one alcoholic drink and 8 mg of Δ⁹‐THCP taken orally in gummy form. The patient stated that the THCP was purchased from a dispensary and noted they did not know this was different from Δ⁹‐THC. The patient noted psychotic symptoms occurring roughly 1 h after consumption, with the effects lasting for 48 h. The patient experienced depersonalization, believed that himself and his family were already dead, and believed that in order to live, he had to kill himself. The patient used a kitchen cleaver to stab himself in the chest. The patient did have a psychiatric history. He reported that 5 years previously, he had cut his wrist while intoxicated because he was feeling depressed. He started therapy at that time but noted not being consistent in seeing his provider. He denied a history of psychosis, psychiatric admissions or of seeing a psychiatrist. Additionally, he denied a family history of psychotic disorders. The patient noted regular cannabis use. The maximum amount of Δ⁹‐THC used in 1 day was 20 mg and no psychotic symptoms occurred with prior use. The patient also noted the consumption of ~20 beers per week.

Following the self‐harm attempt, a prehospital trauma activation was initiated by emergency medical services. The patient became tachypneic and hypoxic while en route to the hospital and required left‐sided needle thoracostomy. Upon arrival to the ED, the patient had an initial blood pressure of 100/60 mmHg and was noted to be pale and sleepy. He was transferred to the trauma bay and became hypotensive, with blood pressure decreasing to 80 s/40 s mmHg. A left‐sided chest tube was placed for traumatic hemothorax and the patient was transfused one unit of whole blood. Blood pressure temporarily improved to 104/71 mmHg following chest tube placement and blood transfusion; however, dropped to 93/46 mmHg with a mean arterial pressure of 62, at which point norepinephrine was started. Once stabilized, the patient was immediately transferred to the operating room for a left anterior thoracotomy, left upper lobe wedge resection and washout, and closure of the self‐inflicted stab wound, during which the patient lost an estimated 1.5 L of blood.

The patient was then transferred to the surgical intensive care unit (SICU) off of any pressure support or sedation. While in the SICU, he became uncooperative with examinations and began to make inappropriate religious remarks, attempted to get out of bed, and forcefully removed his Foley catheter and chest tubes. The patient was noted to have a flat affect, and began to ignore questions. At this point, an electrocardiogram was completed and showed a QTc of 419. The patient was given a single dose 5 mg of haloperidol intravenous (IV) push, and a behavioral health consult was placed.

The consult psychiatrist recommended adding lurasidone 20 mg daily with food to address mood and psychosis as well as 5 mg of haloperidol IV push every 6 h as needed for agitation. Lurasidone was then switched to aripiprazole 5 mg daily given formulary restrictions, though the patient refused all doses of aripiprazole. The mental status exam noted some confusion, a flat affect, and impaired insight and judgement.

During the patient's second day, he remained off of vasopressors and the anterior chest tube was removed. The patient was noted to have left upper extremity swelling on the third day in the SICU. A venous Doppler found an occlusive thrombus in the distal brachial vein, for which a heparin infusion was initiated. Behavioral health recommended adding hydroxyzine pamoate 25 mg every 6 h for anxiety. The mental status exam noted a constricted affect, and poor judgment, but stated the patient had linear thought processes, euthymic mood, and was calm. The patient's posterior chest tube was also removed.

On Day 4, the patient was transitioned to enoxaparin for the management of the upper extremity deep vein thrombosis at a dose of 1 mg/kg twice daily. The patient was medically cleared by trauma surgery for transfer to inpatient psychiatry for further crisis evaluation.

On Day 7 of admission, the patient was transferred to inpatient psychiatry with a psychiatric diagnosis of cannabis‐induced psychotic disorder. The patient refused aripiprazole 5 mg daily. After being seen by the psychiatrist, the medication was discontinued, as the patient denied residual psychotic or psychiatric symptoms. The mental status exam contained no abnormalities at this time. The patient was pleasant and an active participant in the unit. A family meeting was held, the patient agreed to go to inpatient substance use rehabilitation and was discharged to the rehabilitation facility on Day 12 of admission.