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Toxicity, MDMA: Treatment & Medication
Updated: Jan 26, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
Prehospital care is primarily supportive.
- Address the ABCs, administer oxygen, obtain intravenous access, assess blood glucose level, monitor the patient, and perform frequent vital sign checks and serial assessment of consciousness (eg, AVPU [alert, responds to voice, responds to pain, unresponsive], Glasgow Coma Scale).
- Anxiety, extreme agitation, panic reactions, and seizures may require short-acting benzodiazepines (eg, lorazepam) administered intravenously or intramuscularly. Restraints may be necessary if patients exhibit complete loss of control and are dangerous to themselves or others.
Emergency Department Care
While most patients with MDMA overdose improve with supportive care, life-threatening complications may result from severe toxicity. Fatalities have been reported because of severe hyperthermia (ie, heat stroke) accompanied by DIC, rhabdomyolysis, and acute renal failure. Death by cerebral edema and seizures secondary to hyponatremia and SIADH has also been reported. As in any amphetamine toxicity, the danger of cardiac arrhythmias and cardiovascular instability always must be entertained. Careful attention to the airway and vital signs is standard in overdoses, and serial neurologic checks are required.
- Establish ABCs, provide oxygen, obtain intravenous access, and perform cardiac monitoring.
- A bedside glucose determination is indicated in any patient presenting with altered mental status. If a patient is hypoglycemic, administer thiamine and enough glucose to maintain adequate serum glucose concentrations with frequent monitoring.
- If verbal contact is possible, providing reassurance is important. Avoid physical or pharmacologic restraints if possible. Place the patient in a calm, quiet room. If severe agitation or disruptive behavior persists, sedation using benzodiazepines and/or physical restraints may be necessary.
- If acute toxicity caused by ingestion is known, perform GI decontamination by administering activated charcoal. Orogastric lavage usually is not necessary unless a life-threatening co-ingestant is involved and the patient presents within 1 hour of ingestion. Whole-bowel irrigation may be indicated if body packing of drugs is suspected.
- Although respiratory distress is uncommon, endotracheal intubation and mechanical ventilation may be required in patients who cannot protect their airway or have respiratory compromise because of conditions such as seizures, cardiovascular instability, or trauma.
- Patients presenting with severe hyperthermia require aggressive cooling measures and adequate fluid resuscitation. Obtain a rectal temperature. Aggressively cool hyperthermic patients to 102°F. Morbidity is directly related to the severity and duration of hyperthermia.
- Undress the patient.
- Apply evaporative cooling with water and a fan.
- Apply ice packs to the groin and axilla.
- Iced gastric lavage may be considered.
- In extreme cases, the ice-bath immersion may be required for the correction of hyperthermia.
- Control shivering with a benzodiazepine.
- Antipyretics are not useful.
- Treat seizures with benzodiazepines. Most seizures are self-limited and respond well to benzodiazepines. Protect the airway and consider phenobarbital or propofol in patients with refractory symptoms. Treat the underlying cause and check electrolytes, especially hyponatremia. Start with fluid restriction, but consider adding hypertonic saline in refractory or severe cases; in these cases, adding 3% saline and furosemide may be indicated but at a rate no greater than 0.5-1 mEq/L/h.
- Foley catheter placement is indicated to monitor urine output in patients with rhabdomyolysis. Check urinalysis for myoglobin and creatine kinase for rhabdomyolysis. Recognition and treatment of rhabdomyolysis with fluids, alkalinization of the urine, and furosemide may be indicated to prevent acute renal failure. Alkalinization of the urine with sodium bicarbonate is helpful. Administration of furosemide and mannitol may also be considered.
- Obtain cardiac monitoring and ECG in patients complaining of chest pain or palpitations. Order appropriate cardiac enzyme measurements if cardiac injury is suggested. Significant cardiac dysrhythmias may require pharmacotherapy or cardioversion and/or defibrillation.
- Initially, manage hypertension with benzodiazepine sedation. In patients with refractory symptoms or signs of end-organ damage, nitroprusside or nitroglycerin can be used to lower the blood pressure.
- Always perform pregnancy testing in female patients with overdose. MDMA, like all amphetamines, can be toxic to the fetus and may induce miscarriage or premature labor.
Consultations
- A regional poison control center and medical toxicologist can provide valuable information and instructions for handling complex ingestions. Bedside consultation or admission (if necessary) by a medical toxicologist may be beneficial in these situations.
- Obtain psychiatric consultation for patients who demonstrate suicidal thoughts or behavior.
Medication
Objectives in pharmacotherapeutic intervention of MDMA toxicity include the following: (1) decontamination with activated charcoal/sorbitol; (2) sedation with benzodiazepines in agitated and anxious patients; (3) treatment of hyperthermia with rapid convection cooling, spraying water onto the body and using an electric fan to circulate the air, attempting to cool the core temperature to 101°F within 30-45 minutes; (4) relief of muscle spasms and/or cramping with benzodiazepines, (5) prevention of rhabdomyolysis with IV fluids (benefit of furosemide or sodium bicarbonate remains controversial); (6) seizure control with benzodiazepines; and (7) stabilization of hemodynamic and/or cardiovascular disturbances with nitroprusside or nitroglycerin.
Benzodiazepines
These agents are important for sedation, muscle relaxation, and seizure management.
Lorazepam (Ativan)
Beneficial for sedative and anticonvulsant effects. Sedation also can lower amphetamine-induced hypertension. DOC for initial treatment of status epilepticus.
Adult
0.05-0.1 mg/kg (2-4 mg) IV; titrate to effect
Status epilepticus: 4 mg IV over 2-5 min; may repeat second dose in 10-15 min prn; not to exceed 8 mg
Pediatric
Children: 0.05 mg/kg IV (range, 0.02-0.1 mg/kg)
Adolescents: Administer as in adults
Status epilepticus:
Neonates: 0.05 mg/kg over 2-5 min; may repeat in 10-15 min prn
Infants and children: 0.1 mg/kg over 2-5 min; second dose of 0.05 mg/kg IV at 10-15 min prn; not to exceed 4 mg
Adolescents: 0.7 mg/kg; not to exceed 4 mg, given slowly over 2-5 min with second dose in 10-15 min prn
Toxicity in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs
Documented hypersensitivity; narrow-angle glaucoma; altered mental status; low BP or respiratory rate
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Monitor for respiratory depression with high or repeated doses; contains benzyl alcohol, which may be toxic to infants in high doses; caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, Parkinson disease, or patients who may have inhibition of benzodiazepine metabolism and clearance (eg, using nicotine, taking cimetidine); contains propylene glycol and in large doses can cause hypotension and lactic acidosis
Diazepam (Valium, Diazemuls, Diastat)
Depresses all levels of CNS, possibly by increasing activity of GABA; individualize dosage and increase cautiously to avoid adverse effects.
Adult
0.2 mg/kg IV at 2 mg/min; not to exceed 20 mg as a single dose; may repeat, monitoring for respiratory depression
Pediatric
<5 years: 0.2-0.5 mg/kg IV; not to exceed 5 mg
>5 years: 0.2-0.5 mg/kg IV; not to exceed 10 mg
Increases toxicity of benzodiazepines in CNS with coadministration of phenothiazines, barbiturates, cimetidine, alcohols, and MAOIs
Documented hypersensitivity; narrow-angle glaucoma; altered mental status; low BP or respiratory rate
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause altered mental status, respiratory depression, and hypotension; caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity); large infusions can cause propylene glycol toxicity
Barbiturates
Class of anticonvulsants useful when phenytoin and benzodiazepines fail.
Phenobarbital (Luminal, Barbita, Solfoton)
Exhibits anticonvulsant activity in anesthetic doses. In status epilepticus, important to achieve therapeutic levels as quickly as possible. IV dose may require approximately 15 min to attain peak levels in brain.
If IM route is chosen, administer into areas such as one of the large muscles (eg, gluteus maximus, vastus lateralis, other areas with little risk of encountering a nerve trunk or major artery); permanent neurologic deficit may result from injection into or near peripheral nerves.
Restrict IV use to conditions in which other routes are not possible, either because patient is unconscious or because prompt action is required; if used to terminate generalized convulsive status epilepticus, administer up to 15-20 mg/kg.
Ventilation and intubation may be necessary; hypotension may require treatment; a trend exists in recommendations to use agents other than phenobarbital (propofol, midazolam, other barbiturates) for refractory status epilepticus.
Adult
15-20 mg/kg IV; infusion rate not to exceed 100 mg/min
Pediatric
15-20 mg/kg IV over 10-15 min in single or divided dose; some patients may require 5 mg/kg/dose q15-30min until seizure is controlled or 40 mg/kg administered
May decrease effects of chloramphenicol, digitoxin, corticosteroids, carbamazepine, theophylline, verapamil, metronidazole, and anticoagulants (patients stabilized on anticoagulants may require dosage adjustments if added to or withdrawn from their regimen); coadministration with alcohol may produce additive CNS effects and death; chloramphenicol, valproic acid, and MAOIs may increase toxicity; rifampin may decrease effects; induction of microsomal enzymes may result in decreased effects of oral contraceptives in women (must use additional contraceptive methods to prevent unwanted pregnancy); menstrual irregularities also may occur
Documented hypersensitivity; severe respiratory disease; marked impairment of liver function; nephritic patients
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
In prolonged therapy, evaluate hematopoietic, renal, hepatic, and other organ systems; caution in fever, hyperthyroidism, diabetes mellitus, and severe anemia, because adverse reactions can occur; caution in myasthenia gravis and myxedema
Alkalinizing agent
These agents are used to facilitate treatment of rhabdomyolysis.
Sodium bicarbonate (Neut)
Useful in alkalization of urine to prevent acute myoglobinuric renal failure; titrate dose to increase pH to 7.45-7.55; onset of action is within minutes and lasts approximately 15-30 min; monitor blood pH to avoid excess alkalosis. Maintain normal serum potassium level because urinary alkalinization impossible if patient is hypokalemic.
Adult
Bolus 1-2 mEq/kg, followed by an intravenous infusion of 3 ampules of sodium bicarbonate (132 mEq) in 1 L of 5% dextrose in water (D5W) to run at 1.5-2X maintenance fluid range as long as renal function is intact; subsequent dosages guided by urine pH (goal, 7.5-8.0) and hypokalemia must be corrected; serum pH should be maintained at 7.45-7.55
Pediatric
1-2 mEq/kg IV q1-2h prn
Urinary alkalinization, induced by increased sodium bicarbonate concentrations, may cause decreased levels of lithium, tetracyclines, chlorpropamide, methotrexate, and salicylates; increases levels of amphetamines, pseudoephedrine, flecainide, anorexiants, mecamylamine, ephedrine, quinidine, and quinine
Documented hypersensitivity; alkalosis; hypernatremia; hypocalcemia; severe pulmonary edema; unknown abdominal pain
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Only use to treat documented metabolic acidosis and hyperkalemia-induced cardiac arrest; can cause alkalosis, decreased plasma potassium, hypocalcemia, and hypernatremia; caution in electrolyte imbalances (eg, patients with CHF, cirrhosis, edema, corticosteroid use, or renal failure); avoid extravasation because can cause tissue necrosis; caution if <2 y
Osmotic diuretics
These agents increase osmolarity of glomerular filtrate and induce diuresis. They hinder tubular reabsorption of water, causing sodium and chloride excretion to increase.
Mannitol (Osmitrol)
Alternative diuretic used when urine output is inadequate despite aggressive fluid therapy.
Initially assess for adequate renal function in adults by administering test dose of 200 mg/kg IV over 3-5 min; should produce urine flow of at least 30-50 mL/h of urine over 2-3 h.
In children, assess for adequate renal function by administering test dose of 200 mg/kg IV over 3-5 min; should produce urine flow of at least 1 mL/h over 1-3 h.
Adult
1.5-2 g/kg IV as 20% solution (7.5-10 mL/kg) or as 15% solution (10-13 mL/kg) over a period as short as 30 min
Pediatric
Initial: 0.5-1 g/kg IV
Maintenance dose: 0.25-0.5 g/kg IV q4-6h
None reported
Documented hypersensitivity; anuria; severe pulmonary congestion; progressive renal damage; severe dehydration; active intracranial bleeding; progressive heart failure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Carefully evaluate cardiovascular status before rapid administration because sudden increase in extracellular fluid may lead to fulminating CHF; avoid pseudoagglutination; when blood given simultaneously, add at least 20 mEq of sodium chloride to each liter of mannitol solution; do not give electrolyte-free mannitol solutions with blood
Antihypertensives
Design treatment of hypertension to reduce the blood pressure and other risk factors of coronary heart disease. Individualize pharmacologic therapy based on a patient's age, race, known pathophysiologic variables, and concurrent conditions. Design treatment not only to lower blood pressure safely and effectively but also to avoid or reverse hyperlipidemia, glucose intolerance, and left ventricular hypertrophy.
Phentolamine (Regitine)
Alpha1 and alpha2 adrenergic blocking agent that blocks circulating epinephrine and norepinephrine action, reducing hypertension that results from catecholamine effects on alpha-receptors.
Adult
1-2 mg IV initial, then 0.05 mg/kg IV; not to exceed 5 mg
Pediatric
Administer as in adults
Concurrent administration of epinephrine, phenylephrine, or ephedrine may decrease effects; ethanol increases toxicity
Documented hypersensitivity; coronary or cerebral arteriosclerosis; renal impairment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in tachycardia, non–drug-induced angina, coronary artery insufficiency, peptic ulcer, and gastritis; cerebrovascular occlusions and myocardial infarctions can occur following administration
Sodium nitroprusside (Nitropress)
Produces vasodilation and increases inotropic activity of heart; at higher dosages, may exacerbate myocardial ischemia by increasing heart rate.
Adult
0.1-8 mcg/kg/min IV; titrate to effect
Pediatric
Administer as in adults
Coadministration with indomethacin may increase nitrate serum concentrations; sildenafil coadministration causes severe hypotension
Documented hypersensitivity; subaortic stenosis; idiopathic hypertrophic; atrial fibrillation or flutter; hypovolemia; sildenafil (Viagra) use within 24 h
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in increased intracranial pressure, hepatic failure, severe renal impairment, and hypothyroidism; in renal or hepatic insufficiency, nitroprusside levels may increase and can cause cyanide toxicity; monitor for thiocyanate and cyanide or limit use to <24 h (risk of cyanide toxicity is increased with infusions >2 mcg/kg/min); cyanide toxicity can be prevented with prolonged nitroprusside infusions by adding 1 g sodium thiosulfate to each 250 cm3 bag of nitroprusside for infusion; has ability to lower blood pressure (thus, use only in patients with mean arterial pressures >70 mm Hg); not a first-line drug for use in pregnant women unless hypertensive emergency
Nitroglycerin (Nitro-Bid, Nitrostat, Deponit)
Decreases coronary vasospasm, which increases coronary blood flow; in addition, induces vessel dilatation, decreasing cardiac workload.
Adult
400 mcg SL or 5 mcg/min IV; titrate to effect
May administer bolus of 12.5-25 mcg or give 400-mcg tab SL as bolus before continuous infusion; initial infusion rate of 10-20 mcg/min may be increased 5-10 mcg/min q5-10min until desired clinical or hemodynamic response is achieved; infusion rates of 500 mcg/min occasionally have been required
Pediatric
Not established
Aspirin may increase nitrate serum concentrations; marked symptomatic orthostatic hypotension may occur with coadministration of calcium channel blockers (dose adjustment of either agent may be necessary)
Documented hypersensitivity; severe anemia; shock; postural hypotension; head trauma; closed-angle glaucoma; cerebral hemorrhage; hypovolemia; constrictive pericarditis; pericardial effusion; hypertrophic cardiomyopathy; sildenafil (Viagra) use within previous 24 h
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in coronary artery disease, low systolic BP, recent AMI, glaucoma, hepatic disease, and hyperthyroidism
Diuretic
Diuretics facilitate diuresis during treatment of rhabdomyolysis.
Furosemide (Lasix)
Increases excretion of water by interfering with chloride-binding cotransport system, which, in turn, inhibits sodium and chloride reabsorption in ascending loop of Henle and distal renal tubule; potent vasodilator of medullary vessels serving to wash out concentration gradient of countercurrent system, resulting in marked diuresis.
Adult
20-40 mg IV q2h prn to maintain urine output; may increase dose by 20 mg q2h prn to desired response
Pediatric
1-2 mg/kg IV q6h; titrate to desired urine output; not to exceed 6 mg/kg/d
Metformin decreases concentrations; interferes with hypoglycemic effect of antidiabetic agents and antagonizes muscle-relaxing effect of tubocurarine; auditory toxicity appears to be increased with coadministration of aminoglycosides (hearing loss of varying degrees may occur); anticoagulant activity of warfarin may be enhanced when taken concurrently; increased plasma lithium levels and toxicity are possible when taken concurrently
Documented hypersensitivity; hepatic coma; anuria; severe electrolyte depletion
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Perform frequent serum electrolyte, carbon dioxide, glucose, creatinine, uric acid, calcium, and BUN determinations during first few months of therapy and periodically thereafter
GI decontamination
Activated charcoal adsorbs MDMA after acute ingestions and limits absorption into systemic circulation. Most beneficial if administered within 4 hours of ingestion.
Activated charcoal (Liqui-Char, Actidose-Aqua)
Network of pores present in activated charcoal adsorbs 100-1000 mg of drug per gram of charcoal; does not dissolve in water; for maximum effect, administer within 30 min of poison ingestion; may administer as aqueous suspension or combined with cathartic (usually sorbitol 70%) and with presence of active bowel sounds; may need to be repeated (without cathartic) to adsorb large pill masses or drug packages.
Adult
1 g/kg PO/NG (with or without cathartic)
Pediatric
1 g/kg/dose PO
<2 y: Cathartic not recommended
May inactivate ipecac syrup if used concomitantly; effectiveness of other medications decreases with coadministration; do not mix with sherbet, milk, or ice cream (decreases adsorptive properties)
Documented hypersensitivity; poisoning or overdose of mineral acids and alkalies; unprotected airway or absent gag reflex
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor for presence of bowel sounds before administration to minimize risk of charcoal ileus (if bowel sounds are absent or diminished, use aqueous solution to prevent bowel distention); not very effective in poisonings of ethanol, methanol, and iron salts; induce emesis before administration; after emesis with ipecac syrup, patient may not tolerate activated charcoal for 1-2 h; can administer in early stages of gastric lavage; without sorbitol, gastric lavage returns are black
Glucose supplement
This agent is used to raise the patient's serum glucose level.
Dextrose (Glucose-D)
Monosaccharide, absorbed from intestine and distributed, stored, and used by tissues. Parenterally injected dextrose is used in patients unable to obtain adequate oral intake; direct oral absorption results in rapid increase of blood glucose concentrations. Effective in small doses; no evidence indicates that it may cause toxicity; concentrated infusions provide higher amounts of glucose and increased caloric intake with minimum fluid volume.
Adult
IV bolus: 50 mL of 50% dextrose after blood draw
Long-term management: 10% glucose IV infusion in water by central venous line for long-term management; necessary to avoid vein sclerosis that can be caused by glucose infused peripherally; long-term management of hypoglycemia is dictated by cause (ie, insulinoma)
Pediatric
Neonates: 200 mg/kg (2 mL 10% glucose in water per kg) IV bolus
Children: 0.5 g/kg dextrose IV bolus
Caution when administering parenteral fluids to patients receiving corticosteroids or corticotropin, especially if solution contains sodium ions
Diabetic coma if blood sugar levels are extremely high; severe dehydration; do not administer concentrated solution if intraspinal or intracranial hemorrhage is present; dehydrated patients with delirium tremens, hepatic coma, or glucose-galactose malabsorption syndrome
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause nausea, which also may occur with hypoglycemia; IV dextrose solutions may result in dilution of serum electrolyte concentrations or overhydration when fluid overload is present; caution in patients suffering from congested states or pulmonary edema; hypertonic dextrose given peripherally may cause thrombosis (administer instead through central venous catheter); caution in subclinical diabetes mellitus or carbohydrate intolerance; increased risk of inducing significant hyperglycemia or hyperosmolar syndrome if solution is administered rapidly, especially in patients with chronic uremia or carbohydrate intolerance; concentrated solutions should not be administered IM/SC; rates of dextrose infusion >0.5 g/kg/h may produce glycosuria; at infusion rates of 0.8 g/kg/h, the incidence of glycosuria is 5%; monitor fluid balance, electrolyte concentrations, and acid-base balance closely; dextrose administration may produce vitamin B-complex deficiency
Vitamin supplementation
Vitamins are indicated to correct thiamine deficiency and prevent Wernicke-Korsakoff encephalopathy.
Thiamine (Vitamin B-1)
Supplementation ensures adequate cofactor for maintenance of cellular aerobic respiration. CNS depletion of thiamine may result in Wernicke encephalopathy.
Adult
100 mg IV initial; followed by 50-100 mg/d IV/IM
Pediatric
50 mg IV initial; followed by 10-25 mg/d IV/IM
None reported
Documented hypersensitivity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Sensitivity reactions can occur (intradermal test dose recommended when sensitivity is suspected); deaths have resulted from IV use; sudden onset or worsening of Wernicke encephalopathy, following glucose, may occur in thiamine-deficient patients; administer before or together with dextrose-containing fluids when thiamine deficiency is suspected
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| Differential Diagnoses & Workup: Toxicity, MDMA |
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Further Reading
Keywords
MDMA toxicity, MDMA, MDMA intoxication, MDMA overdose, ecstasy overdose, ecstasy, XTC, 3,4-methylenedioxymethamphetamine,amphetamine derivative, psychoactive drug, euphoria, 3,4-methylenedioxyamphetamine, MDA, hallucinogenic amphetamine, rave drugs
