Ecstasy toxicity

💡 Key Point: MDMA (“Ecstasy”) toxicity is most often due to hyponatraemia and hyperthermia — not the drug itself. MDMA triggers SIADH and thirst, while prolonged dancing and fluid intake cause water overload → rapid sodium fall → cerebral oedema, seizures, and death. Young women are especially vulnerable. 🚨

🧠 About

• MDMA (3,4-Methylenedioxymethamphetamine) is a synthetic amphetamine derivative that powerfully releases serotonin (5-HT), dopamine, and noradrenaline.
• Produces feelings of euphoria, emotional warmth, empathy, and energy — the so-called “entactogenic” effect.
• Commonly used at clubs and festivals; dehydration, crowd heat, and prolonged dancing amplify risks. 🎶
• Street tablets are often adulterated with other stimulants (amphetamine, PMA, cathinones), increasing mortality. ⚠️
• Repeated use leads to tolerance and serotonergic neuronal depletion → low mood and cognitive decline over time.

⚙️ Pathophysiology & Mechanisms

• 🧩 Serotonin storm: Massive serotonin release causes agitation, hyperthermia, and sometimes serotonin syndrome.
• 💧 SIADH: Inappropriate ADH release → water retention → dilutional hyponatraemia.
• 🥤 Water-loading behaviour: Users often over-hydrate (“keep drinking water”), worsening sodium drop.
• 🔥 Hyperthermia: From muscle rigidity, prolonged exertion, and environmental heat → risk of rhabdomyolysis, DIC, and liver failure.
• 👩‍⚕️ Gender risk: Premenopausal females are most prone to hyponatraemic cerebral oedema — likely hormonal modulation of water balance.

🩺 Clinical Presentation

• 😃 Behavioural: Euphoria, increased confidence, sociability, restlessness.
• 💓 Autonomic: Tachycardia, hypertension, sweating, tremor, mydriasis.
• 🦷 Neuromuscular: Bruxism, trismus, hyperreflexia, clonus, hypertonia.
• 🌀 Psychiatric: Agitation, paranoia, hallucinations, panic, aggression.
• 💀 Severe toxicity: Seizures, coma, hyperthermia (>40 °C), acute liver failure, DIC, rhabdomyolysis, and renal failure.

⚠️ Major Complications & Management Focus

🔬 Investigations

• 🧪 Bloods: U&E (focus on Na⁺), LFTs, CK, FBC, glucose, coagulation, and VBG (for lactate & acidosis).
• 💉 Urine tox screen: Confirm MDMA / exclude co-ingestants.
• 📈 ECG: Check for QT prolongation or arrhythmia.
• 🌡️ Monitoring: Continuous temperature, heart rhythm, and urine output for early AKI detection.

💉 Management Summary

• 🩹 1️⃣ ABCDE: Support airway, give O₂, monitor vitals; treat seizures with IV Diazepam 5–10 mg.
• 💧 2️⃣ Fluid strategy: Gentle IV 0.9% saline if hypovolaemic; avoid over-hydration.
• 🧂 3️⃣ Hyponatraemia: Slow correction — hypertonic saline only if seizures/coma. ITU if Na⁺ < 120 mmol/L.
• 🔥 4️⃣ Hyperthermia: Rapid active cooling; IV Dantrolene if severe rigidity.
• 🧘 5️⃣ Agitation: Diazepam (preferred); avoid Haloperidol if serotonin syndrome suspected.
• 📊 6️⃣ Ongoing care: ECG & electrolyte monitoring for 24 h; early senior or toxicology input (ToxBase, NPIS).

📈 Prognosis

• Most patients recover fully with timely supportive therapy. 🕊️
• Deaths usually result from severe hyponatraemia, hyperthermia, or multiorgan failure.
• Chronic use → depression, anxiety, and memory impairment due to serotonergic neuronal loss.

📚 References

• ToxBase: MDMA (Ecstasy) poisoning
• NICE CKS: Stimulant drug toxicity
• Henry JA et al. Medical problems of dance-party drugs. BMJ 1992; 305:5-9.
• Liechti ME. MDMA pharmacology and toxicology: a brief overview. Psychopharmacology 2017; 234:1317-1328.

🧩 Summary: MDMA toxicity is a triad of serotonin excess, water intoxication, and heat injury. Think “Hot + HypoNa⁺ = Ecstasy collapse.” Treat rapidly but gently — cool fast, correct slow — and always involve poisons or ITU early. 🏥