Ecstasy (MDMA) toxicity: Difference between revisions

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'''<span style="display: none" id="1346780227555S">&nbsp;</span>Background'''
==Background==
 
[[File:MDMA.png|thumbnail|MDMA]]
[[File:Ecstasy monogram.jpg|thumb|Ecstasy tablets containing MDMA]]
*3,4-methylenedioxymethamphetamine (MDMA)  
*3,4-methylenedioxymethamphetamine (MDMA)  
*other names:&nbsp;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"&nbsp;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&nbsp;contain 50-100mg of ecstatsy (although other substances possible)
**Typical tablets contain 50-100mg of MDMA
 
'''Clinical Features'''
 
*most people report euphoria
*AMS
*agitation
*tachycardia, palpitations, HTN
*serotonin syndrome (AMS, hyperthermia, rigidity, autonomic instability)
*GI&nbsp;symptoms
*dehydration
*bruxism (jaw clenching/grinding)
*hyperthermia
*hyponatremia (from sweat loss, free water intake, and SIADH&nbsp;like effect)
*seizure
*mydriasis
*hepatotoxicity
 
'''Workup'''


*Accucheck, ISTAT
==Clinical Features==
*urine pregnancy
*Euphoria
*CBC, BMP, LFTs, coags, tylenol, aspirin
*Agitation
*CK
*Tachycardia, palpitations, hypertension
*ECG
*UA
*Tox screen, blood alcohol
*serum osmoles, urine Na&nbsp;(if hyponatremia present)
*Head CT as indicated
*LP as indicated to rule out meningitis


'''Treatment'''
{| 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>
|}


*ABCs
==Differential Diagnosis==
*IV, O2, monitor
{{Sympathomimetic types}}
*Agitation:&nbsp;benzos, haldol
{{Drugs of abuse types}}
*Seizure:&nbsp;benzos, phenobarbital (20mg/kg), propofol; avoid dilantin; manage airway as indicated&nbsp;
*Seizure AND&nbsp;hyponatremia:&nbsp;hypertonic saline (3% NS) 2-3 ml/kg IV&nbsp;bolus until sz stops (need to raise serum Na by 3-5 meq/L)
*Hyponatremia:&nbsp;fluids restrict most pt's, unless hypovolemic. correct Na slowly: 0.5 meq/h; 10-12 meq/24h
*Hyperthermia:&nbsp;ice packs, cold IVF, consider dantrolene 1mg/kg IV
*Rhabdo:&nbsp;foley, IVF


'''Disposition'''
==Evaluation==
{{Hallucinogen workup}}
*Urine tox fails to detect unless large doses
**More usually positive test for amphetamines
**Confirmation must use specialized lab tests (gas chromatography)


*Admit pt's with complications of ingestion
==Management==
*Discharge those who are asymptomatic and no life threatening complication
*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


<br>
==Disposition==
*Consider discharge if all symptoms resolve and no complications noted
*Otherwise admit


'''Sources'''
==References==
<references/>


Harwood-Nuss, Rosens, EMedicine
==See Also==
*[[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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