Morning Report: 4/9/2013

Thanks to Dr. Yeo for today’s Morning Report!

Here’s the Case:

A 22 year-old male patient is brought in by EMS from a nearby club for seizures. On arrival he is lethargic, hypertensive, febrile, and tachycardic. He is accompanied by his friend who reports the patient ingested multiple tablets of ecstasy throughout the night.

MDMA Toxicity

• 3,4-methylenedioxymethamphetamine (MDMA) [ie, ecstasy) is an amphetamine derivative
• Discovered by Köllisch in 1912 at a German pharmaceutical company, Merck
• Causes catecholamine release from presynaptic vesicles and is a selective serotonergic neurotoxin that causes massive release of serotonin
• Animal models have demonstrated long-term destruction of 5-HT axons
• Causes euphoria, loss of inhibition, a feeling of closeness and/or empathy, and increased sensuality
• Available as a tablet, capsule, powder, and liquid
• Duration of action is 8-24 hours with a half-life of 12-34 hours, depending on purity
• Metabolized in the liver and excreted renally.

Cardiovascular effects

• Autonomic hyperactivity
• Amphetamine-induced catecholamine and 5-HT surge that causes tachycardia, hypertension, and hyperthermia
• Hyperthermia one of the main causes of fatalities
• Fatal dysrhythmias have been reported including vfib and asystole

Serotonin syndrome

• Hyperthermia, AMS, autonomic instability, altered muscle tone and/or rigidity
• Vigorous dancing for long hrs can predispose patients to hyperthermia, dehydration, and muscle breakdown leading to rhabdo
• Further complications include DIC, hepatotoxicity, and ARF

Hyponatremia

• The occurrence of hyponatremia is multifactorial
  • increased water intake
  • excessive sweating with physical exertion
  • release of vasopressin leading to SIADH
• In severe cases, patients can develop cerebral edema with subsequent seizures and coma

• Other less common side effects include intracerebral hemorrhage, infarcts, and liver failure

Long-term neuropsychiatric effects

• Long term effects related to decrease in serotonin reuptake transporter (SERT) function and numbers
• Recovery of SERT may take weeks and months
• Chronic use may lead to permanent serotonergic damage of the axons
• Causes depression, anxiety, panic attacks, and insomnia after

Management

• ABCs, IV, O2, monitor
• Fingerstick
• Treat agitation with benzos
• Restraints for severe agitation
• Consider activated charcoal if ingested substance known
• Aggressively cool hyperthermic patients to 102°F (Morbidity is directly related to the severity and duration of hyperthermia)
  • Undress
  • Evaporative cooling with water and a fan
  • Ice packs to the groin and axilla
  • Iced gastric lavage may be considered
  • Consider ice-bath immersion if available
  • Control shivering with a benzos
  • Antipyretics not useful
  • Dantrolene (1 mg/kg or 80 mg IV)
• Treat seizures with benzos
• Check electrolytes for hyponatremia
  • Fluid restriction
  • Consider adding hypertonic saline in refractory or severe cases
  • Do not correct at a rate any greater than 0.5-1 mEq/L/h
• Check renal function, liver enzymes, coags
• Foley catheter, monitor output
• Check UA and CK for rhabdo
• If ingestion of MDMA is unclear, consider working up infectious etiology
• Call NYC poison control center (212-POISONS) for assistance

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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