BACKGROUND: In March and April 2018, more than 150 patients presented to 
hospitals in Illinois with coagulopathy and bleeding diathesis. Area physicians 
and public health organizations identified an association between coagulopathy 
and synthetic cannabinoid use. Preliminary tests of patient serum samples and 
drug samples revealed that brodifacoum, an anticoagulant, was the likely 
adulterant.
METHODS: We reviewed physician-reported data from patients admitted to Saint 
Francis Medical Center in Peoria, Illinois, between March 28 and April 21, 2018, 
and included in a case series adult patients who met the criteria used to 
diagnose synthetic cannabinoid-associated coagulopathy. A confirmatory 
anticoagulant poisoning panel was ordered at the discretion of the treating 
physician.
RESULTS: A total of 34 patients were identified as having synthetic 
cannabinoid-associated coagulopathy during 45 hospitalizations. Confirmatory 
anticoagulant testing was performed in 15 of the 34 patients, and superwarfarin 
poisoning was confirmed in the 15 patients tested. Anticoagulant tests were 
positive for brodifacoum in 15 patients (100%), difenacoum in 5 (33%), 
bromadiolone in 2 (13%), and warfarin in 1 (7%). Common symptoms at presentation 
included gross hematuria in 19 patients (56%) and abdominal pain in 16 (47%). 
Computed tomography was performed to evaluate abdominal pain and revealed renal 
abnormalities in 12 patients. Vitamin K1 (phytonadione) was administered orally 
in all 34 patients and was also administered intravenously in 23 (68%). Red-cell 
transfusion was performed in 5 patients (15%), and fresh-frozen plasma infusion 
in 19 (56%). Four-factor prothrombin complex concentrate was used in 1 patient. 
One patient died from complications of spontaneous intracranial hemorrhage.
CONCLUSIONS: Our data indicate that superwarfarin adulterants of synthetic 
cannabinoids can lead to clinically significant coagulopathy. In our series, in 
most of the cases in which the patient presented with bleeding diathesis, 
symptoms were controlled with the use of vitamin K1 replacement therapy. The 
specific synthetic cannabinoid compounds are not known.