Ecstasy (MDMA) toxicity

Background

MDMA

Ecstasy tablets containing MDMA

• 3,4-methylenedioxymethamphetamine (MDMA)
• Also known as: Ecstasy, 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

Hallucinogen, designer drug, and club drug toxicities

• Serotonin-Like Agents
  • Lysergic acid diethylamide toxicity (LSD)
  • Psilocybin toxicity ("magic mushrooms")
  • N,N-Dimethyltryptamine toxicity (DMT)
  • 5-methoxy- dimethyltryptamine (5-MeO-DMT)
  • 25C-NBOMe toxicity
• Enactogens
  • Designer amphetamines
  • Bath salts toxicity
  • Ecstasy (MDMA) toxicity
  • Mescaline toxicity (peyote)
  • Synthetic cannabinoid toxicity
• Dissociative Agents
  • Phencyclidine toxicity (PCP)
  • Ketamine
  • Dextromethorphan toxicity
  • Nitrous oxide toxicity
• Plant-based Hallucinogenics
  • Marijuana toxicity
  • Salvia toxicity
  • Absinthe toxicity
  • Isoxazole Mushrooms
  • Hawaiian baby woodrose (Argyreia nervosa)
  • Hawaiian woodrose (Merremia tuberosa)
  • Morning glory (Ipomoea violacea)
  • Olili- uqui (Rivea corymbosa)

Clinical Features

• Euphoria
• Agitation
• Tachycardia, palpitations, hypertension

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 Seizure Hallucinations Loss of consciousness Serotonin syndrome
Musculoskeletal		Hypertonia Rhabdomyolysis
Respiratory		Acute respiratory distress syndrome
Urinary		Acute kidney injury
Other		Cerebral edema Hepatitis Hyperpyrexia Hyponatremia (from sweat loss, free water intake, and SIADH-like effect)

Differential Diagnosis

Sympathomimetic toxicities

• Cocaine toxicity
• Amphetamine toxicity
  • Synthetic cathinone toxicity (khat)
• Ketamine
• Ecstasy (MDMA) toxicity
• Synthetic cannabinoid toxicity
• Bath salts toxicity

Drugs of abuse

• 25C-NBOMe‎
• Alcohol
• Amphetamines
• Bath salts
• Cocaine
• Difluoroethane
• 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

Diagnosis

• Urine tox fails to detect unless large doses
  • More usually positive test for amphetamines
  • Confirmation must use specialized lab tests (gas chromatography)

Toxidrome Chart

Finding	Cholinergic	Anticholinergic	Sympathomimetic	Sympatholytic^	Sedative/Hypnotic
Example	Organophosphates	TCAs	Cocaine	Clonidine	ETOH
Temp	Nl	Nl / ↑	Nl / ↑	Nl / ↓	Nl / ↓
RR	Variable	Nl / ↓	Variable	Nl / ↓	Nl / ↓
HR	Variable	↑	↑ (sig)	Nl / ↓	Nl / ↓
BP	↑	↑	↑	Nl / ↓	Nl / ↓
LOC	Nl / Lethargic	Nl, agitated, psychotic, comatose	Nl, agitated, psychotic	Nl, Lethargic, or Comatose	Nl, Lethargic, or Comatose
Pupils	Variable	Mydriatic	Mydriatic	Nl / Miotic
Motor	Fasciculations, Flacid Paralysis	Nl	Nl / Agitated	Nl
Skin	Sweating (sig)	Hot, dry	Sweating	Dry
Lungs	Bronchospasm / rhinorrhea	Nl	Nl	Nl
Bowel Sounds	Hyperactive (SLUDGE)	↓ / Absent	Nl / ↓	Nl / ↓

^Consider Sympatholytic when looking at Sedative OD or someone who doesn't respond to Narcan

Withdrawal from substances have the opposite effect

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