What are the primary features of an ecstasy (3,4-Methyl​enedioxy​methamphetamine) overdose?

Features of Ecstasy (MDMA) Overdose

The primary features of ecstasy (3,4-Methylenedioxymethamphetamine, MDMA) overdose include hyperthermia, hyponatremia, serotonin syndrome, rhabdomyolysis, cardiovascular effects, and neurological manifestations that can progress to life-threatening multi-organ failure.

Cardiovascular Manifestations

• Tachycardia and hypertension (common)
• QT prolongation on ECG
• Arrhythmias
• Cardiovascular collapse in severe cases 1

Neurological Manifestations

• Altered mental status ranging from agitation to coma
• Seizures (seen in approximately 36.5% of cases requiring intensive care) 2
• Mydriasis (pupil dilation)
• Bruxism (teeth grinding)
• Headache
• Dizziness and weakness (reported in 15.4% of emergency presentations) 3

Thermoregulatory Effects

• Hyperthermia (high fever) - one of the most significant and potentially fatal complications
• Core temperature can exceed 40°C (104°F) in severe cases
• Hyperthermia can trigger a cascade of other complications 4

Metabolic Abnormalities

• Hyponatremia (low sodium) - a major life-threatening complication
• Metabolic acidosis
• Dehydration
• Syndrome of inappropriate antidiuretic hormone secretion (SIADH) 2

Muscle and Kidney Effects

• Rhabdomyolysis (muscle breakdown)
• Acute kidney injury
• Elevated creatine kinase levels 2, 3

Liver Effects

• Elevated liver enzymes
• Acute liver failure in severe cases 2

Hematologic Effects

• Disseminated intravascular coagulation (DIC) in severe cases
• Coagulopathy 2

Risk Factors for Severe Toxicity

• High ambient temperature
• Vigorous physical activity (dancing)
• Inadequate fluid intake
• Concomitant use of other substances (particularly alcohol, cocaine, GHB, or opiates)
• Multiple tablet ingestion 5

Clinical Course and Complications

The severity of ecstasy overdose can vary significantly based on several factors:

1. Dose-related effects: While even 1-2 tablets can cause severe reactions, massive overdoses (>10 tablets) dramatically increase risk 5

2. Polysubstance use: Co-ingestion significantly alters clinical presentation:

   • Cocaine + MDMA: Increased panic reactions (30.7% vs 7.7% with MDMA alone)
   • GHB/opiates + MDMA: Deep coma in 68.8% of cases (vs 0% with MDMA alone) 3

3. Environmental factors: Dancing in hot environments with limited fluid intake worsens hyperthermia 5

Management Approach

1. Prioritize standard resuscitation measures:

   • Airway management and respiratory support
   • Cardiovascular stabilization
   • Cooling measures for hyperthermia 1

2. Specific interventions:

   • Aggressive cooling for hyperthermia
   • Careful fluid management for hyponatremia
   • Benzodiazepines for seizures and agitation
   • Monitor for and treat rhabdomyolysis 2

3. Monitoring requirements:

   • Continuous cardiac monitoring
   • Frequent neurological assessments
   • Serial electrolyte measurements
   • Renal and liver function tests 2, 3

Prognosis

The mortality rate from ecstasy overdose is relatively low, but severe cases can lead to:

• Prolonged ICU stays (average 4.3±2.1 days in severe cases)
• Potential for persistent neurological deficits
• Multi-organ failure requiring prolonged support 2

Important Caveats

• The unpredictability of adverse reactions makes even single-dose use potentially dangerous
• Symptoms can progress rapidly from seemingly mild to life-threatening
• Early recognition and aggressive management are essential to prevent mortality
• MDMA metabolism is complex and involves enzyme inhibition that can make subsequent doses more toxic 6