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)
- 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 status
- Severe sympathomimetic symptoms
- Central nervous system:
- Excitation
- Coma
- Seizures
- Cerebral edema
- Cardiovascular:
- Hypertension (early)
- Hypotension (late)
- Palpitations
- Ventricular tachycardia and ectopy
- Pulmonary:
- Metabolic:
- Hyponatremia
- Hypoglycemia
- Syndrome of inappropriate antidiuretic hormone
- Musculoskeletal:
- Bruxism
- Restlessness
- Rigidity
- Renal:
- Hepatic:
- Hematologic:
- Disseminated intravascular coagulation
- Gastrointestinal:
- Vomiting
- Diarrhea
- Abdominal cramping
- Psychiatric:
- Euphoria
- Flight of ideas
- Delirium/hallucinations
- Other:
- Hyperthermia
- Mydriasis
- Nystagmus
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:
- Pacifiers
- Glow sticks
- Surgical 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:
- Nitroprusside
- Phentolamine
- Esmolol
- Hypotension:
- 0.9% NS IV bolus
- Trendelenburg position
- Pressors 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 IV
- Consider sodium bicarbonate administration.
- Hemodialysis if renal failure
- Hyperthermia:
- Standard cooling measures
- Treat 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)