Ecstasy (MDMA)

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MDMA

Background

  • 3,4-methylenedioxymethamphetamine (MDMA)
  • other names:;E, X, XTC, Adam, Stacy
  • causes catecholamine release, serotonin release, and inhibits serotonin re-uptake
  • "rave";parties
  • 1-2mg/kg effective dose; onset 30min-1 hour, peak 4 hours, lasts 8-24 hours
  • typical tablets;contain 50-100mg of ecstatsy (although other substances possible)

Clinical Features

Workup

  • Urine pregnancy
  • CBC, Metabolic panel, LFTs, coags, APAP level, ASA level
  • Total CK level
  • ECG
  • UA
  • Tox screen, blood alcohol
  • Serum osmoles, urine Na (if Hyponatremia present)
  • Head CT as indicated
  • LP to rule out Meningitis if infectious symptoms and based on history and physical
  • Urine tox fails to detect unless large doeses
    • More usually positive test for amphetamines
    • Confirmation must use specialized lab tests (gas chromatography)
  • Chest pain work up if applicable
  • Blood and urine cultures if signs of infection
  • Consider LP to exclude meningitis

Differential Diagnosis

Sympathomimetics

Management

Prehospital

  • Primary focus should be on controlling agitation as well as ABCs

ABCs

  • IV, O2, monitor

Agitation

Seizure

Seizure AND Hyponatremia

  • Adults: 3% NS 100cc bolus over 10min; repeat after 10min x1 if no improvement[3]
    • Each 100 ml will raise sodium by ~2 mmol/l
    • In general, 200-400 mL of 3% NaCl is reasonable dose in most adult patients with severe symptomatic hyponatremia, which may be given IV over 1-2 hr until resolution of seizures.
  • Pediatrics: 2 cc/kg of 3% over 10-60 minutes can be infused with a repeat of up to 3 times.[4]
  • Goal should be to raise serum Na by 3-5 meq/L)

Hyponatremia

  • Fluids restrict most patients, unless hypovolemic.
  • Correct Na slowly: 0.5 meq/h; 10-12 meq/24h

Hyperthermia

  • Ice packs, cold IVF,
  • Rhabdomyolysis
    • Foley, IVF, goal urine output > 2cc/kg

Disposition

  • Admit patient's with complications of ingestion
  • Discharge those who are asymptomatic and no life threatening complication

References

  1. Aitchison KJ, Tsapakis EM, Huezo-Diaz P, Kerwin RW, Forsling ML, Wolff K. Ecstasy (MDMA)-induced hyponatraemia is associated with genetic variants in CYP2D6 and COMT. J Psychopharmacol. 2012;26(3):408-18
  2. Carvalho M, Pontes H, Remiao F, Bastos ML, Carvalho F. Mechanisms underlying the hepatotoxic effects of ecstasy. Curr Pharm Biotechnol. 2010;11(5):476-95
  3. Spasovski et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Nephrol Dial Transplant (2014) 0: 1–39. fulltext
  4. Moritz ML, Ayus JC. 100cc 3% sodium chloride bolus: a novel treatment for hyponatremic encephalopathy. Metab Brain Dis. 2010 Mar; 25(1): 91-6.

See Also