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MDMA Poisoning, Emergency Medicine

Basics

Description

- MDMA: 3,4-methylenedioxymethamphetamine ( "ecstasy " ) - Schedule I drug manufactured illegally - Used recreationally: - Rave parties - Dance clubs - College campuses

- Onset of effects: 15 " 30 min after ingestion - Duration of effects: 2 " 6 hr - Pills commonly contain contaminants: - Caffeine - Ephedrine - Dextromethorphan - Ketamine - Related methylated amphetamines: 3,4-methylenedioxyamphetamine (MDA), 3,4-methylenedioxy-N-ethylamphetamine (MDEA), 3,4-methylenedioxy-N-butylamphetamine (MDBA), para-methoxyamphetamine (PMA)

- Central nervous system: - Excitation - Coma - Seizures - Cerebral edema

- Cardiovascular: - Hypertension (early) - Hypotension (late) - Palpitations - Ventricular tachycardia and ectopy

- Musculoskeletal: - Bruxism - Restlessness - Rigidity

- Gastrointestinal: - Vomiting - Diarrhea - Abdominal cramping

- Psychiatric: - Euphoria - Flight of ideas - Delirium/hallucinations

- Other: - Hyperthermia - Mydriasis - Nystagmus

- Transport all pills/pill bottles involved in overdose for identification in ED. - Watch for MDMA paraphernalia: - Pacifiers - Glow sticks - Surgical masks

- Hypotension: - 0.9% NS IV bolus - Trendelenburg position - Pressors titrated to blood pressure

  • MDMA: 3,4-methylenedioxymethamphetamine ( "ecstasy " )
  • Schedule I drug manufactured illegally
  • Used recreationally:Rave partiesDance clubsCollege campuses
  • Onset of effects: 15 " 30 min after ingestion
  • Duration of effects: 2 " 6 hr
  • Pills commonly contain contaminants:CaffeineEphedrineDextromethorphanKetamineRelated methylated amphetamines: 3,4-methylenedioxyamphetamine (MDA), 3,4-methylenedioxy-N-ethylamphetamine (MDEA), 3,4-methylenedioxy-N-butylamphetamine (MDBA), para-methoxyamphetamine (PMA)
  • Pathophysiology:Amphetamine-like structure stimulates catecholamine release.Mescaline-like ring structure enhances serotonergic and dopaminergic activity.

Etiology

Deliberate or accidental ingestion of MDMA

Diagnosis

Signs and Symptoms

  • Overdose:Altered mental statusSevere sympathomimetic symptoms
  • Central nervous system:ExcitationComaSeizuresCerebral edema
  • Cardiovascular:Hypertension (early)Hypotension (late)PalpitationsVentricular tachycardia and ectopy
  • Pulmonary:
  • Metabolic:HyponatremiaHypoglycemiaSyndrome of inappropriate antidiuretic hormone
  • Musculoskeletal:BruxismRestlessnessRigidity
  • Renal:
  • Hepatic:
  • Hematologic:Disseminated intravascular coagulation
  • Gastrointestinal:VomitingDiarrheaAbdominal cramping
  • Psychiatric:EuphoriaFlight of ideasDelirium/hallucinations
  • Other:HyperthermiaMydriasisNystagmus

Essential Workup

  • Diagnosis based on clinical presentation and an accurate history.
  • Obtain core temperature.
  • Exclude toxic coingestants or contaminants.

Diagnosis Tests & Interpretation

Lab

  • Electrolytes, BUN, creatinine, and glucose levels
  • Prothrombin time, partial thromboplastin time, international normalized ratio
  • Urine dip for blood and myoglobin
  • Creatine phosphokinase level if rhabdomyolysis suspected
  • Liver function tests for significant overdose or suspected hepatitis
  • Urine toxicology screen to exclude coingestants:May cause positive amphetamine and methamphetamine screen
  • Quantitative MDMA levels rarely helpful

Imaging

  • CXR if suspected aspiration pneumonia
  • Head CT if suspected intracranial hemorrhage

Diagnostic Procedures/Surgery

ECG:

  • Sinus tachycardia (most common)
  • Dysrhythmias, conduction disturbances

Differential Diagnosis

  • Cocaine overdose
  • Amphetamine overdose
  • Anticholinergic overdose
  • Cathinone overdose (e.g., Bath salts)
  • Serotonin syndrome
  • Occult head injury
  • Sepsis
  • Thyroid storm
  • Pheochromocytoma

Treatment

Pre-Hospital

  • Transport all pills/pill bottles involved in overdose for identification in ED.
  • Watch for MDMA paraphernalia:PacifiersGlow sticksSurgical masks

Initial Stabilization/Therapy

ABCs:

  • Airway control is essential.
  • Administer supplemental oxygen.
  • Intubate if indicated.
  • IV access
  • Naloxone, thiamine, dextrose (or Accu-Chek), if altered mental status

Ed Treatment/Procedures

  • Supportive care
  • Monitor core temperature and cardiac rhythm for at least 6 hr.
  • Hydrate with 0.9% normal saline (NS) IV
  • Hypertension:NitroprussidePhentolamineEsmolol
  • Hypotension:0.9% NS IV bolusTrendelenburg positionPressors titrated to blood pressure
  • Anxiety, restlessness, agitation:Diazepam or lorazepam as needed
  • Seizures:Treat initially with benzodiazepines.Phenobarbital for persistent seizures
  • Rhabdomyolysis:Hydrate aggressively with 0.9% NS IVConsider sodium bicarbonate administration.Hemodialysis if renal failure
  • Hyperthermia:Standard cooling measuresTreat agitation with benzodiazepines.

Medication

  • Diazepam: 5 " 10 mg (peds: 0.2 " 0.5 mg/kg) IV q10 " 15min
  • Esmolol: 500 Όg/kg IV bolus, then 50 Όg/kg/min IV
  • Lorazepam: 2 " 6 mg (peds: 0.05 " 0.1 mg/kg) IV q10 " 15min
  • Naloxone: 0.4 " 2 mg (peds: 0.1 mg/kg; neonatal: 10 " 30 mg/kg) IV or IM
  • Nitroprusside: 0.3 mg/kg/min to max. 10 Όg/kg/min
  • Phenobarbital: 10 " 20 mg/kg IV (loading dose)
  • Phentolamine: 1 " 5 mg (peds: 0.02 " 0.1 mg/kg) IV bolus q5 " 10min
  • Propofol: 0.5 " 1.0 mg/kg IV (loading dose), then 5 " 50 mg/kg/min (maintenance dose)

Follow-Up

Disposition

Admission Criteria

  • Altered mental status
  • Seizures
  • Persistent cardiovascular instability
  • Rhabdomyolysis
  • Loss of behavioral control
  • Disseminated intravascular coagulation

Discharge Criteria

Asymptomatic 6 hr after oral overdose

Follow-Up Recommendations

  • Substance abuse referral for patients with recreational drug abuse
  • Patients with unintentional (accidental) poisoning require poison prevention counseling.
  • Patients with intentional (e.g., suicide) poisoning require psychiatric evaluation.

Pearls and Pitfalls

  • Always obtain a core temperature.
  • Concomitant recreational drugs might not be present on a routine hospital drug screen.
  • For persistent altered mental status, assess electrolytes for hyponatremia.
  • Consider nontoxicologic causes for altered mental status.

Additional Reading

  • Centers for Disease Control and Prevention. Ecstasy overdoses at a New Years Eve rave " Los Angeles, California, 2010. MMWR Morb Mortal Wkly Rep. 2010;59(22):677 " 681.
  • Gahlinger PM. Club drugs: MDMA, gamma-hydroxybutyrate (GHB), Rohypnol, and ketamine. Am Fam Physician. 2004;69:2619 " 2626.
  • Halpern P, Moskovich J, Avrahami B, et al. Morbidity associated with MDMA (ecstasy) abuse: A survey of emergency department admissions. Hum Exp Toxicol 2011;30(4):259 " 266.
  • Patel MM, Wright DW, Ratcliff JJ, et al. Shedding new light on the "safe " club drug: Methylenedioxymethamphetamine (ecstasy)-related fatalities. Acad Emerg Med. 2004;11(2):208 " 210.
  • Rosenson J, Smollin C, Sporer KA, et al. Patterns of ecstasy-associated hyponatremia in California. Ann Emerg Med. 2007;49(2):164 " 171.

Codes

ICD9

969.72 Poisoning by amphetamines

ICD10

  • T43.621A Poisoning by amphetamines, accidental (unintentional), init
  • T43.623A Poisoning by amphetamines, assault, initial encounter
  • T43.624A Poisoning by amphetamines, undetermined, initial encounter

SNOMED

  • 212670004 Ecstasy poisoning (disorder)
  • 291258000 Accidental ecstasy poisoning (disorder)
  • 291259008 Intentional ecstasy poisoning (disorder)
  • 291260003 Ecstasy poisoning of undetermined intent (disorder)