From the Guidelines
For a patient with MDMA overdose presenting with GCS 3 and severe hyperthermia, immediate aggressive management is essential to prevent morbidity and mortality. The primary goal is to rapidly cool the patient and stabilize their vital signs.
- Secure the airway through intubation and provide ventilatory support to prevent respiratory failure.
- Rapidly cool the patient using ice packs to axilla, groin, and neck, cold IV fluids (30ml/kg), and cooling blankets, targeting a temperature below 39°C, as hyperthermia is a significant contributor to morbidity and mortality in these patients 1.
- Administer IV fluids (normal saline) to address dehydration and hypotension, which are common in MDMA toxicity.
- For seizures, give benzodiazepines such as diazepam 5-10mg IV or lorazepam 2-4mg IV, as they can help control muscular activity and prevent further complications.
- Monitor and correct electrolyte abnormalities, particularly hyponatremia, which is common in MDMA toxicity, and check creatine kinase levels for rhabdomyolysis.
- Maintain urine output at 1-2ml/kg/hr with IV fluids if rhabdomyolysis is present, to prevent acute kidney injury.
- Continuous cardiac monitoring is necessary due to the risk of arrhythmias associated with MDMA overdose and hyperthermia.
- Avoid dopamine antagonists like haloperidol as they may worsen hyperthermia, and instead consider the use of benzodiazepines and other supportive measures to control symptoms.
- Consider activated charcoal (50g) only if recent ingestion and protected airway, as it may help reduce the absorption of MDMA. The key to managing a patient with MDMA overdose and severe hyperthermia is rapid and aggressive supportive care, with a focus on temperature control, stabilization of vital signs, and prevention of further complications.
From the FDA Drug Label
OVERDOSAGE ... Symptoms which may occur in case of overdose include, but are not limited to, muscular weakness and alterations in the state of consciousness (e.g., lethargy, coma), vomiting, diarrhea, and crystalluria. For acute overdosage, general supportive measures should be employed. The FDA drug label does not answer the question.
From the Research
Initial Assessment
- A patient with a 3-3-3 Glasgow Coma Scale (GCS) score and severe hyperthermia due to 3,4-Methylenedioxymethamphetamine (MDMA) overdose requires immediate attention 2, 3, 4, 5, 6.
- The initial assessment should include monitoring of vital signs, blood glucose levels, and serum electrolytes, as hyperthermia and hypoglycemia are common complications of MDMA overdose 2, 3, 4.
Management of Hyperthermia
- Severe hyperthermia should be treated with aggressive cooling methods, including sedation with benzodiazepines, intravenous fluid replacement, and mechanical ventilation if necessary 3, 4, 5.
- The goal is to rapidly lower the body temperature to prevent further organ damage and improve outcomes 4, 5.
Monitoring and Supportive Care
- Patients with MDMA overdose should be closely monitored for signs of end-organ damage, including renal failure, rhabdomyolysis, and disseminated intravascular coagulation 4, 5, 6.
- Supportive care, including cardiac monitoring, respiratory support, and renal replacement therapy, may be necessary in severe cases 4, 5, 6.
- Frequent monitoring of blood glucose levels is crucial, as hypoglycemia can occur due to endogenous hyperinsulinemia induced by MDMA 2.
Specific Considerations
- The management of MDMA-induced hyperthermia and other complications requires a multidisciplinary approach, involving emergency medicine, critical care, and toxicology specialists 3, 4, 5, 6.
- Clinicians should be aware of the potential for severe hyperthermia and other life-threatening complications in patients with MDMA overdose, and be prepared to provide aggressive treatment and supportive care 2, 3, 4, 5, 6.