Ecstasy (MDMA) toxicity

MDMA

Background

• 3,4-methylenedioxymethamphetamine (MDMA)
• other names: E, X, XTC, Adam, Stacy
• causes catecholamine release, serotonin release, and inhibits serotonin re-uptake
• "rave" parties
• 1-2 mg/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
• AMS
• agitation
• 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

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
  • Positive test for amphetamines if only large doses
  • 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

• ABCs
• IV, O2, monitor
• Agitation
  • benzos
  • 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

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

Sources

Harwood-Nuss, Rosens, EMedicine