Ecstasy (MDMA) toxicity

Background

MDMA

Ecstasy tablets containing MDMA

• 3,4-methylenedioxymethamphetamine (MDMA)
• Also known as: 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
• Hyperthermia
• Hyponatremia (from sweat loss, free water intake, and SIADH-like effect)
• Seizure
• Serotonin syndrome

System	Minor or moderate overdose	Severe overdose
Cardiovascular		Disseminated intravascular coagulation Intracranial hemorrhage Severe hypertension or hypotension Hypotensive bleeding
Central nervous system	Hyperreflexia Agitation Confusion Paranoia Stimulant psychosis	Cognitive deficit Coma Convulsions Hallucinations Loss of consciousness Serotonin syndrome
Musculoskeletal		Hypertonia Rhabdomyolysis
Respiratory		Acute respiratory distress syndrome
Urinary		Acute kidney injury
Other		Cerebral edema Hepatitis Hyperpyrexia Hyponatremia (SIADH)

Differential Diagnosis

Sympathomimetics

• Cocaine
• Amphetamines
  • Synthetic cathinones (khat)
• Ketamine
• Ecstasy (MDMA)
• Synthetic cannabinoids
• Bath salts

Drugs of abuse

• 25C-NBOMe‎
• Alcohol
• Amphetamines
• Bath salts
• Cocaine
• Ecstasy
• Gamma hydroxybutyrate (GHB)
• Heroin
• Inhalant abuse
  • Hydrocarbon toxicity
  • Difluoroethane (electronics duster)
• Marijuana
• Kratom
• Phencyclidine (PCP)
• Psilocybin ("magic mushrooms")
• Synthetic cannabinoids
• Chloral hydrate
• Body packing

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

See Also

• Sympathomimetic toxicity
• Amphetamines