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