Ecstasy (MDMA) toxicity: Difference between revisions

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==Background==
[[File:MDMA.png|thumbnail|MDMA]]
[[File:MDMA.png|thumbnail|MDMA]]
==Background==
[[File:Ecstasy monogram.jpg|thumb|Ecstasy tablets containing MDMA]]
*3,4-methylenedioxymethamphetamine (MDMA)  
*3,4-methylenedioxymethamphetamine (MDMA)  
*other names: E, X, XTC, Adam, Stacy
*Also known as: Ecstasy, X, Molly, Skittles, Smartees, Beans
*causes catecholamine release, serotonin release, and inhibits serotonin re-uptake  
*Popular at "rave" parties and EDM festivals
*"rave" parties
*Causes catecholamine release, serotonin release, and inhibits serotonin re-uptake  
*1-2 mg/kg effective dose; onset 30min-1 hour, peak 4 hours, lasts 8-24 hours  
*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)
**Typical tablets contain 50-100mg of MDMA


==Clinical Features==
==Clinical Features==
*most people report euphoria
*Euphoria
*AMS
*Agitation
*agitation
*Tachycardia, palpitations, hypertension
*tachycardia, palpitations, HTN
*serotonin syndrome (AMS, 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)
*seizure
*mydriasis
*hepatotoxicity


==Workup==
{| class="wikitable"
|-
! System
!  Minor or moderate overdose || Severe overdose
|-
! Cardiovascular
|
||
* [[Disseminated intravascular coagulation]]
* [[Intracranial hemorrhage]]
* Severe [[hypertension]] or [[hypotension]]
* Hypotensive bleeding
|-
! Central nervous<br />system
|
* Hyperreflexia
* Agitation
* Confusion
* Paranoia
* Stimulant psychosis
|
* Cognitive deficit
* Coma
* [[Seizure]]
* [[Hallucinations]]
* Loss of consciousness
* [[Serotonin syndrome]]
|-
! Musculoskeletal
|
|
* Hypertonia
* [[Rhabdomyolysis]]
|-
! Respiratory
|
|
* [[Acute respiratory distress syndrome]]
|-
! Urinary
|
|
* [[Acute kidney injury]]
|-
! Other
|
|
* Cerebral edema
* [[Hepatitis]]
* [[Hyperpyrexia]]
*[[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>
|}
 
==Differential Diagnosis==
{{Sympathomimetic types}}
{{Drugs of abuse types}}
 
==Evaluation==
{{Hallucinogen workup}}
{{Hallucinogen workup}}
*Urine tox fails to detect unless large doeses
*Urine tox fails to detect unless large doses
**Positive test for amphetamines if only large doses
**More usually positive test for amphetamines
**Confirmation must use specialized lab tests (gas chromatography)
**Confirmation must use specialized lab tests (gas chromatography)
*Chest pain w/u if CP present
*Blood and urine cultures if signs of infection
*Consider LP to exclude meningitis


==Treatment==
==Management==
*ABCs
*Supportive care is mainstay of treatment
*IV, O2, monitor
*[[Benzodiazepines]] for agitation, severe hypertension
*Agitation
*Hyperthermia may be severe and requires immediate treatment with active cooling measures
**benzos
**Morbidity/mortality is related to severity and length of hyperthermia
**haldol
*Seizure:
**benzos
**phenobarbital (20mg/kg), propofol
**avoid dilantin
**manage airway as indicated
*Seizure AND Hyponatremia
**hypertonic saline (3% NS) 2-3 ml/kg IV
***bolus until sz stops (need to raise serum Na by 3-5 meq/L)
*Hyponatremia:
**fluids restrict most pt's, unless hypovolemic. correct Na slowly: 0.5 meq/h; 10-12 meq/24h
*Hyperthermia:
**ice packs, cold IVF, consider dantrolene 1mg/kg IV
*Rhabdo
**foley, IVF


==Disposition==
==Disposition==
*Admit pt's with complications of ingestion
*Consider discharge if all symptoms resolve and no complications noted
*Discharge those who are asymptomatic and no life threatening complication
*Otherwise admit
 
==References==
<references/>


==Sources==
==See Also==
Harwood-Nuss, Rosens, EMedicine
*[[Sympathomimetic toxicity]]
*[[Amphetamines]]


[[Category:Tox]]
[[Category:Toxicology]]

Latest revision as of 20:10, 12 January 2021

Background

MDMA
Ecstasy tablets containing MDMA
  • 3,4-methylenedioxymethamphetamine (MDMA)
  • Also known as: Ecstasy, 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

  • Euphoria
  • Agitation
  • Tachycardia, palpitations, hypertension
System Minor or moderate overdose Severe overdose
Cardiovascular
Central nervous
system
  • Hyperreflexia
  • Agitation
  • Confusion
  • Paranoia
  • Stimulant psychosis
Musculoskeletal
Respiratory
Urinary
Other

Differential Diagnosis

Sympathomimetics

Drugs of abuse

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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