Difference between revisions of "Ecstasy (MDMA)"

Revision as of 23:58, 9 May 2017

MDMA

Background

• 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
• altered mental status
• Agitation
• Tachycardia, palpitations, hypertension
• Serotonin Syndrome (altered mental status, 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) ^[1]
• Seizure
• Mydriasis
• Hepatotoxicity^[2]

Differential Diagnosis

Sympathomimetics

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

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

Prehospital

• Primary focus should be on controlling agitation as well as ABCs

ABCs

• IV, O2, monitor
• Airway: Intubate if necessary
• Breathing: not expected to cause hypoxia, consider other dx or concurrent problem (aspiration PNA)
• Circulation: severe hypertension
  • benzodiazepines first line
  • Consider nitroprusside or phentolamine, avoid beta blockers (unopposed alpha stimulation)

Agitation

• Sedation with Benzodiazepines as needed
• Avoid Haldol, interferes with heat dissipation, may prolong QTc, may reduce seizure threshold

Seizure

• Benzodiazepines
• Phenobarbital (20mg/kg) or propofol as second line agents
  • avoid dilantin
  • manage airway as indicated

Seizure AND Hyponatremia

• Adults: 3% NS 100cc bolus over 10min; repeat after 10min x1 if no improvement^[3]
  • Each 100 ml will raise sodium by ~2 mmol/l
  • In general, 200-400 mL of 3% NaCl is reasonable dose in most adult patients with severe symptomatic hyponatremia, which may be given IV over 1-2 hr until resolution of seizures.
• Pediatrics: 2 cc/kg of 3% over 10-60 minutes can be infused with a repeat of up to 3 times.^[4]
• Goal should be to raise serum Na by 3-5 meq/L)

Hyponatremia

• Fluids restrict most patients, unless hypovolemic.
• Correct Na slowly: 0.5 meq/h; 10-12 meq/24h

Hyperthermia

• Ice packs, cold IVF,
• Rhabdomyolysis
  • Foley, IVF, goal urine output > 2cc/kg

Gastrointestinal decontamination

• Activated charcoal for recent ingestion (< 1 hour)
• Patient must be protecting airway or intubated

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
2. ↑ 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
3. ↑ Spasovski et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Nephrol Dial Transplant (2014) 0: 1–39. fulltext
4. ↑ Moritz ML, Ayus JC. 100cc 3% sodium chloride bolus: a novel treatment for hyponatremic encephalopathy. Metab Brain Dis. 2010 Mar; 25(1): 91-6.

See Also

• Sympathomimetic toxicity
• Amphetamines