Difference between revisions of "Ecstasy (MDMA)"

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(Simplified management section)
 
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[[File:MDMA.png|thumbnail|MDMA]]
 
 
==Background==
 
==Background==
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[[File:MDMA.png|thumbnail|MDMA]]
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*3,4-methylenedioxymethamphetamine (MDMA)  
 
*3,4-methylenedioxymethamphetamine (MDMA)  
 
*Also known as: X, Molly, Skittles, Smartees, Beans
 
*Also known as: X, Molly, Skittles, Smartees, Beans
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==Clinical Features==
 
==Clinical Features==
 
*Euphoria  
 
*Euphoria  
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*[[altered mental status]]
 
 
*Agitation  
 
*Agitation  
 
*Tachycardia, palpitations, hypertension  
 
*Tachycardia, palpitations, hypertension  
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*[[Serotonin Syndrome]] ([[altered mental status]], [[Hyperthermia]], rigidity, autonomic instability)
 
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*rhabdomyolysis, myoglobinuria
 
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*[[DIC]]
 
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*GI symptoms
 
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*[[Dehydration]]
 
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*Bruxism (jaw clenching/grinding)
 
 
*[[Hyperthermia]]  
 
*[[Hyperthermia]]  
 
*[[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>
 
*[[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>
 
*[[Seizure]]
 
*[[Seizure]]
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*Mydriasis
 
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*Hepatotoxicity<ref>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</ref>
 
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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==Management==
 
==Management==
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===Prehospital===
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*Supportive care is mainstay of treatment
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*Primary focus should be on controlling agitation as well as ABCs
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*[[Benzodiazepines]] for agitation, severe hypertension
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*Hyperthermia may be severe and requires immediate treatment with active cooling measures
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===ABCs===
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**Morbidity/mortality is related to severity and length of hyperthermia
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*IV, O2, monitor
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* Airway: Intubate if necessary
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* Breathing: not expected to cause hypoxia, consider other dx or concurrent problem (aspiration PNA)
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*Circulation: severe hypertension
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**benzodiazepines first line
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**Consider nitroprusside or phentolamine, avoid beta blockers (unopposed alpha stimulation)
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===Agitation===
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*Sedation with [[Benzodiazepines]] as needed
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*Avoid Haldol, interferes with heat dissipation, may prolong QTc, may reduce seizure threshold
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===[[Seizure]]===
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*[[Benzodiazepines]]
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*[[Phenobarbital]] (20mg/kg) or [[propofol]] as second line agents
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**avoid [[dilantin]]
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**manage airway as indicated
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===Seizure AND Hyponatremia===
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{{Symptomatic Hyponatremia Treatment}}
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*Goal should be to raise serum Na by 3-5 meq/L)
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===[[Hyponatremia]]===
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*Fluids restrict most patients, unless hypovolemic.
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*Correct Na slowly: 0.5 meq/h; 10-12 meq/24h
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===[[Hyperthermia]]===
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*Ice packs, cold IVF,
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*[[Rhabdomyolysis]]
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**Foley, IVF, goal urine output > 2cc/kg
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===Gastrointestinal decontamination===
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*[[Activated charcoal]] for recent ingestion (< 1 hour)
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*Patient must be protecting airway or intubated
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==Disposition==
 
==Disposition==

Latest revision as of 02:21, 10 May 2017

Background

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

Differential Diagnosis

Sympathomimetics

Evaluation

  • 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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