Ecstasy (MDMA) toxicity: Difference between revisions

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==Background==
[[File:MDMA.png|thumbnail|MDMA]]
[[File:MDMA.png|thumbnail|MDMA]]
==Background==
 
*3,4-methylenedioxymethamphetamine (MDMA)  
*3,4-methylenedioxymethamphetamine (MDMA)  
*Also known as: X, Molly, Skittles, Smartees, Beans
*Also known as: X, Molly, Skittles, Smartees, Beans
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==Clinical Features==
==Clinical Features==
*Euphoria  
*Euphoria  
*[[altered mental status]]
*Agitation  
*Agitation  
*Tachycardia, palpitations, hypertension  
*Tachycardia, palpitations, hypertension  
*[[Serotonin Syndrome]] ([[altered mental status]], [[Hyperthermia]], rigidity, autonomic instability)
*rhabdomyolysis, myoglobinuria
*[[DIC]]
*GI symptoms
*[[Dehydration]]
*Bruxism (jaw clenching/grinding)
*[[Hyperthermia]]  
*[[Hyperthermia]]  
*[[Hyponatremia]] (from sweat loss, free water intake, and SIADH-like effect) <ref>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</ref>
*[[Hyponatremia]] (from sweat loss, free water intake, and SIADH-like effect) <ref>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</ref>
*[[Seizure]]
*[[Seizure]]
*Mydriasis
*[[Serotonin syndrome]]
*Hepatotoxicity<ref>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</ref>


==Differential Diagnosis==
==Differential Diagnosis==
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==Management==
==Management==
===Prehospital===
*Supportive care is mainstay of treatment
*Primary focus should be on controlling agitation as well as ABCs
*[[Benzodiazepines]] for agitation, severe hypertension
 
*Hyperthermia may be severe and requires immediate treatment with active cooling measures
===ABCs===
**Morbidity/mortality is related to severity and length of hyperthermia
*IV, O2, monitor
* Airway: Intubate if necessary
* Breathing: not expected to cause hypoxia, consider other dx or concurrent problem (aspiration PNA)
*Circulation: severe hypertension
**benzodiazepines first line
**Consider nitroprusside or phentolamine, avoid beta blockers (unopposed alpha stimulation)
 
===Agitation===
*Sedation with [[Benzodiazepines]] as needed
*Avoid Haldol, interferes with heat dissipation, may prolong QTc, may reduce seizure threshold
 
===[[Seizure]]===
*[[Benzodiazepines]]
*[[Phenobarbital]] (20mg/kg) or [[propofol]] as second line agents
**avoid [[dilantin]]
**manage airway as indicated
 
===Seizure AND Hyponatremia===
{{Symptomatic Hyponatremia Treatment}}
*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
 
===Gastrointestinal decontamination===
*[[Activated charcoal]] for recent ingestion (< 1 hour)
*Patient must be protecting airway or intubated


==Disposition==
==Disposition==

Revision as of 15:52, 16 February 2018

Background

MDMA
  • 3,4-methylenedioxymethamphetamine (MDMA)
  • Also known as: X, Molly, Skittles, Smartees, Beans
  • Popular at "rave" parties and EDM festivals
  • Causes catecholamine release, serotonin release, and inhibits serotonin re-uptake
  • 1-2mg/kg effective dose; onset 30min-1 hour, peak 4 hours, lasts 8-24 hours
    • Typical tablets contain 50-100mg of MDMA

Clinical Features

Differential Diagnosis

Sympathomimetics

Evaluation

Hallucination 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 doses
    • More usually positive test for amphetamines
    • Confirmation must use specialized lab tests (gas chromatography)

Management

  • Supportive care is mainstay of treatment
  • Benzodiazepines for agitation, severe hypertension
  • Hyperthermia may be severe and requires immediate treatment with active cooling measures
    • Morbidity/mortality is related to severity and length of hyperthermia

Disposition

  • Consider discharge if all symptoms resolve and no complications noted
  • Otherwise admit

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

See Also

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