MDMA (ecstasy) intoxication in adolescents and adults: Rapid overview of emergency management

To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222 for the nearest regional poison control center. Contact information for poison control centers around the world is available at the WHO website and in the UpToDate topic on regional poison control centers (society guideline links).

Clinical features

MDMA is a serotonergic amphetamine that generally causes feelings of euphoria, empathy, excitement, and wellbeing

Patients with MDMA toxicity may exhibit CNS agitation, hypertension, tachycardia, and hyperthermia

MDMA intoxication can cause severe hyponatremia, seizures, and obtundation. Serotonin syndrome can occur.

Laboratory evaluation

Obtain the following:

Fingerstick glucose, electrocardiogram, acetaminophen and aspirin levels, and pregnancy test (when appropriate)
Basic chemistries, to assess serum sodium and creatinine
Creatinine kinase, for evidence of rhabdomyolysis
Liver function testing and coagulation profiles in severely ill patients

Treatment

Secure airway, breathing, and circulation: standard rapid sequence medications may be used; treat severe hypertension initially with benzodiazepines (eg, lorazepam, 1 to 2 mg IV push, may repeat as needed; or in the absence of IV access midazolam 3 to 5 mg intramuscularly, may repeat as needed)

Give one dose of activated charcoal (1 g/kg; maximum dose 50 g) for ingestions less than one hour if airway protected

Agitation and/or seizures: give benzodiazepines (eg, lorazepam 1 to 2 mg IV push or midazolam 3 to 5 mg IM; may repeat as needed); DO NOT give butyrophenones (eg, haloperidol); DO NOT give phenytoin

Chest pain: give oxygen, aspirin and nitroglycerin if chest pain does not respond to benzodiazepines; DO NOT administer beta-blocking agents

Hyperthermia: active external cooling, benzodiazepines; DO NOT give antipyretics

Hyponatremia: fluid restriction if hyponatremia is mild or moderate (above 115 mEq/dL)

Hyponatremia with persistent seizure: benzodiazepines (eg, lorazepam 1 to 2 mg IV push or midazolam 3 to 5 mg IM; may repeat as needed); hypertonic saline (3% or 513 mEq/L), if serum sodium 115 mEq/dL or less, give 100 mL as IV bolus; if seizures persist, give one or two additional doses of 100 mL, with each dose given over 10 minutes; DO NOT give additional hypertonic or normal saline; monitor serum sodium closely; DO NOT give phenytoin

MDMA: 3,4-methylenedioxymethamphetamine.

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MDMA (ecstasy) intoxication in adolescents and adults: Rapid overview of emergency management