Ecstasy (MDMA) toxicity: Difference between revisions
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===Agitation=== | ===Agitation=== | ||
**Sedation with [[Benzodiazepines]] as needed | **Sedation with [[Benzodiazepines]] as needed | ||
** | **Avoid Haldol, interferes with heat dissipation, may prolong QTc, may reduce seizure threshold | ||
===[[Seizure]]=== | ===[[Seizure]]=== | ||
*[[Benzodiazepines]] | *[[Benzodiazepines]] | ||
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*[[Rhabdomyolysis]] | *[[Rhabdomyolysis]] | ||
**Foley, IVF, goal urine output > 2cc/kg | **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 07:11, 6 May 2017
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
- Most people report euphoria
- altered mental status
- agitation
- tachycardia, palpitations, hypertension
- Serotonin Syndrome (altered mental status, Hyperthermia, rigidity, autonomic instability)
- rhabdomyolysis, myoglobinuria
- DIC
- GI symptoms
- Dehydration
- Bruxism (jaw clenching/grinding)
- Hyperthermia
- Hyponatremia (from sweat loss, free water intake, and SIADH-like effect) [1]
- Seizure
- Mydriasis
- Hepatotoxicity[2]
Workup
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 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
Differential Diagnosis
Sympathomimetics
- Cocaine
- Amphetamines
- Synthetic cathinones (khat)
- Ketamine
- Ecstasy (MDMA)
- Synthetic cannabinoids
- Bath salts
Management
Prehospital
- Primary focus should be on controlling agitation as well as ABCs
ABCs
- 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
Template: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
- Admit patient's with complications of ingestion
- Discharge those who are asymptomatic and no life threatening complication
References
- ↑ 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
- ↑ 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