Rosen & Barkin's 5-Minute Emergency Medicine Consult (440 page)

• MDMA: 3,4-methylenedioxymethamphetamine (“ecstasy”)
  
• Schedule I drug manufactured illegally
  
• Used recreationally:
  
  • Rave parties
    
  • Dance clubs
    
  • College campuses
    
• Onset of effects: 15–30 min after ingestion
  
• Duration of effects: 2–6 hr
  
• Pills commonly contain contaminants:
  
  • Caffeine
    
  • Ephedrine
    
  • Dextromethorphan
    
  • Ketamine
    
  • Related methylated amphetamines: 3,4-methylenedioxyamphetamine (MDA), 3,4-methylenedioxy-
    N
    -ethylamphetamine (MDEA), 3,4-methylenedioxy-
    N
    -butylamphetamine (MDBA),
    para
    -methoxyamphetamine (PMA)
    
• Pathophysiology:
  
  • Amphetamine-like structure stimulates catecholamine release.
    
  • Mescaline-like ring structure enhances serotonergic and dopaminergic activity.
    

Deliberate or accidental ingestion of MDMA

DIAGNOSIS

• Overdose:
  
  • Altered mental status
    
  • Severe sympathomimetic symptoms
    
• Central nervous system:
  
  • Excitation
    
  • Coma
    
  • Seizures
    
  • Cerebral edema
    
• Cardiovascular:
  
  • Hypertension (early)
    
  • Hypotension (late)
    
  • Palpitations
    
  • Ventricular tachycardia and ectopy
    
• Pulmonary:
  
  • Pulmonary edema
    
• Metabolic:
  
  • Hyponatremia
    
  • Hypoglycemia
    
  • Syndrome of inappropriate antidiuretic hormone
    
• Musculoskeletal:
  
  • Bruxism
    
  • Restlessness
    
  • Rigidity
    
• Renal:
  
  • Rhabdomyolysis
    
• Hepatic:
  
  • Jaundice
    
  • Hepatitis
    
• Hematologic:
  
  • Disseminated intravascular coagulation
    
• Gastrointestinal:
  
  • Vomiting
    
  • Diarrhea
    
  • Abdominal cramping
    
• Psychiatric:
  
  • Euphoria
    
  • Flight of ideas
    
  • Delirium/hallucinations
    
• Other:
  
  • Hyperthermia
    
  • Mydriasis
    
  • Nystagmus
    

• Diagnosis based on clinical presentation and an accurate history.
  
• Obtain core temperature.
  
• Exclude toxic coingestants or contaminants.
  

• Electrolytes, BUN, creatinine, and glucose levels
  
• Prothrombin time, partial thromboplastin time, international normalized ratio
  
• Urine dip for blood and myoglobin
  
• Creatine phosphokinase level if rhabdomyolysis suspected
  
• Liver function tests for significant overdose or suspected hepatitis
  
• Urine toxicology screen to exclude coingestants:
  
  • May cause positive amphetamine and methamphetamine screen
    
• Quantitative MDMA levels rarely helpful
  

• CXR if suspected aspiration pneumonia
  
• Head CT if suspected intracranial hemorrhage
  

ECG:

• Sinus tachycardia (most common)
  
• Dysrhythmias, conduction disturbances
  

• Cocaine overdose
  
• Amphetamine overdose
  
• Anticholinergic overdose
  
• Cathinone overdose (e.g., Bath salts)
  
• Serotonin syndrome
  
• Occult head injury
  
• Sepsis
  
• Thyroid storm
  
• Pheochromocytoma
  

TREATMENT

• Transport all pills/pill bottles involved in overdose for identification in ED.
  
• Watch for MDMA paraphernalia:
  
  • Pacifiers
    
  • Glow sticks
    
  • Surgical masks
    

ABCs:

• Airway control is essential.
  
• Administer supplemental oxygen.
  
• Intubate if indicated.
  
• IV access
  
• Naloxone, thiamine, dextrose (or Accu-Chek), if altered mental status
  

• Supportive care
  
• Monitor core temperature and cardiac rhythm for at least 6 hr.
  
• Hydrate with 0.9% normal saline (NS) IV
  
• Hypertension:
  
  • Nitroprusside
    
  • Phentolamine
    
  • Esmolol
    
• Hypotension:
  
  • 0.9% NS IV bolus
    
  • Trendelenburg position
    
  • Pressors titrated to blood pressure
    
• Anxiety, restlessness, agitation:
  
  • Diazepam or lorazepam as needed
    
• Seizures:
  
  • Treat initially with benzodiazepines.
    
  • Phenobarbital for persistent seizures
    
• Rhabdomyolysis:
  
  • Hydrate aggressively with 0.9% NS IV
    
  • Consider sodium bicarbonate administration.
    
  • Hemodialysis if renal failure
    
• Hyperthermia:
  
  • Standard cooling measures
    
  • Treat agitation with benzodiazepines.
    

• Diazepam: 5–10 mg (peds: 0.2–0.5 mg/kg) IV q10–15min
  
• Esmolol: 500 μg/kg IV bolus, then 50 μg/kg/min IV
  
• Lorazepam: 2–6 mg (peds: 0.05–0.1 mg/kg) IV q10–15min
  
• Naloxone: 0.4–2 mg (peds: 0.1 mg/kg; neonatal: 10–30 mg/kg) IV or IM
  
• Nitroprusside: 0.3 mg/kg/min to max. 10 μg/kg/min
  
• Phenobarbital: 10–20 mg/kg IV (loading dose)
  
• Phentolamine: 1–5 mg (peds: 0.02–0.1 mg/kg) IV bolus q5–10min
  
• Propofol: 0.5–1.0 mg/kg IV (loading dose), then 5–50 mg/kg/min (maintenance dose)
  

FOLLOW-UP

• Altered mental status
  
• Seizures
  
• Persistent cardiovascular instability
  
• Rhabdomyolysis
  
• Loss of behavioral control
  
• Disseminated intravascular coagulation
  

Asymptomatic 6 hr after oral overdose

• Substance abuse referral for patients with recreational drug abuse
  
• Patients with unintentional (accidental) poisoning require poison prevention counseling.
  
• Patients with intentional (e.g., suicide) poisoning require psychiatric evaluation.
  

• Always obtain a core temperature.
  
• Concomitant recreational drugs might not be present on a routine hospital drug screen.
  
• For persistent altered mental status, assess electrolytes for hyponatremia.
  
• Consider nontoxicologic causes for altered mental status.
  

• Centers for Disease Control and Prevention. Ecstasy overdoses at a New Year’s Eve rave–Los Angeles, California, 2010.
  MMWR Morb Mortal Wkly Rep
  . 2010;59(22):677–681.
  
• Gahlinger PM. Club drugs: MDMA, gamma-hydroxybutyrate (GHB), Rohypnol, and ketamine.
  Am Fam Physician
  . 2004;69:2619–2626.
  
• Halpern P, Moskovich J, Avrahami B, et al. Morbidity associated with MDMA (ecstasy) abuse: A survey of emergency department admissions.
  Hum Exp Toxicol
  2011;30(4):259–266.
  
• Patel MM, Wright DW, Ratcliff JJ, et al. Shedding new light on the “safe” club drug: Methylenedioxymethamphetamine (ecstasy)-related fatalities.
  Acad Emerg Med
  . 2004;11(2):208–210.
  
• Rosenson J, Smollin C, Sporer KA, et al. Patterns of ecstasy-associated hyponatremia in California.
  Ann Emerg Med
  . 2007;49(2):164–171.
  

CODES

969.72 Poisoning by amphetamines

BASICS