Makindo Medical Notes

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Check local/national poisons advice. MDMA can cause a sudden rise in SIADH, which, in conjunction with exercise, potomania, and opiate use, can lead to an abrupt fall in sodium (Na), increasing the risk of cerebral edema and seizures.

About

• Tolerance Development: MDMA use often leads to tolerance, requiring higher doses to achieve the same euphoric effects over time.
• CNS Effects: Known for causing significant central nervous system serotonin (5HT) release, MDMA profoundly affects mood, behavior, and social interaction.
• Popularity and Risks: Commonly used recreationally, particularly in club and festival settings, MDMA poses risks due to its pharmacological effects and the potential for adulteration with other substances.

Aetiology

• Fluid Imbalance: Excessive thirst and fluid intake combined with MDMA-induced SIADH can lead to severe hyponatremia, resulting in seizures and cerebral edema.
• Gender Susceptibility: Premenopausal women appear particularly susceptible to complications arising from acute hyponatremia, possibly due to hormonal influences.

Clinical Presentation

• Behavioral Changes: Increased alertness, euphoria, extroverted behavior, heightened talkativeness, and rapid speech.
• Physical Symptoms: Lack of desire for food or sleep, tremors, dilated pupils, tachycardia, and hypertension.
• Psychiatric Symptoms: Paranoid delusions, hallucinations, and occasional violent behavior.
• Neuromuscular Symptoms: Hypertonia, hyperreflexia, bruxism (teeth grinding), trismus, and extreme thirst.
• Severe Cases: Can progress to seizures, coma, and other life-threatening conditions if not managed promptly.

Complications

• DIC and Liver Failure: Risk of bleeding due to disseminated intravascular coagulation (DIC) and fulminant liver failure, especially in overdose cases.
• Renal Complications: Rarely, acute kidney injury (AKI) and rhabdomyolysis may occur, particularly with severe overheating or exertion.
• Metabolic Disturbances: Hyperthermia and acute hyponatremia are common complications that require immediate attention.

Investigations

• Laboratory Tests: Conduct U&E, CK, FBC, blood glucose, and LFTs to assess the extent of toxicity and monitor renal and hepatic function.
• Urine Analysis: May help in confirming MDMA use and rule out other substances.
• Electrolytes Monitoring: Pay special attention to sodium levels, as they guide management of hyponatremia.

Management

• Initial Assessment: Supportive care with an ABCDE approach is critical. Assess airway, breathing, circulation, disability, and exposure.
• Fluid Management: Consider IV 0.9% saline if Na levels are normal and the patient is euvolemic or hypovolemic. Avoid excessive fluid administration in cases of significant hyponatremia.
• Hyponatraemia Management: Management depends on fluid balance, sodium level, and clinical status. Consult with experts, as correction of hyponatremia should be carefully titrated (< 12 mmol/L over 24 hours), using hypertonic saline for severe cases. ITU admission and ECG monitoring may be necessary for severe cases.
• Medications: Use diazepam or haloperidol for agitation; diazepam can also control seizures. Avoid neuroleptics that could exacerbate symptoms.
• Hyperthermia Management: Actively cool the patient with ice packs or cooling blankets and administer IV fluids to manage body temperature.
• Monitor for Complications: Be vigilant for signs of hepatic failure, seizures, and other specific complications. Consider administering dantrolene for hyperthermia if indicated.
• Consultation: Seek senior guidance early, especially in cases of marked hyponatremia, significant neurological symptoms, or complications requiring specialized care.