Medication Summary
Objectives in pharmacotherapeutic intervention of MDMA toxicity include the following:
- Decontamination with activated charcoal/sorbitol
- Sedation with benzodiazepines in agitated and anxious patients
- Relief of muscle spasms and/or cramping with benzodiazepines
- Prevention of rhabdomyolysis with IV fluids (benefit of furosemide or sodium bicarbonate remains controversial)
- Seizure control with benzodiazepines
- Stabilization of hemodynamic and/or cardiovascular disturbances with nitroprusside or nitroglycerin.
Benzodiazepines
Lorazepam (Ativan)
Beneficial for sedative and anticonvulsant effects. Sedation also can lower amphetamine-induced hypertension. DOC for initial treatment of status epilepticus.
Diazepam (Valium, Diazemuls, Diastat)
Depresses all levels of CNS, possibly by increasing activity of GABA; individualize dosage and increase cautiously to avoid adverse effects.
Barbiturates
Phenobarbital (Luminal, Barbita, Solfoton)
Exhibits anticonvulsant activity in anesthetic doses. In status epilepticus, important to achieve therapeutic levels as quickly as possible. IV dose may require approximately 15 min to attain peak levels in brain.
If IM route is chosen, administer into areas such as one of the large muscles (eg, gluteus maximus, vastus lateralis, other areas with little risk of encountering a nerve trunk or major artery); permanent neurologic deficit may result from injection into or near peripheral nerves.
Restrict IV use to conditions in which other routes are not possible, either because patient is unconscious or because prompt action is required; if used to terminate generalized convulsive status epilepticus, administer up to 15-20 mg/kg.
Ventilation and intubation may be necessary; hypotension may require treatment; a trend exists in recommendations to use agents other than phenobarbital (propofol, midazolam, other barbiturates) for refractory status epilepticus.
Alkalinizing agent
Sodium bicarbonate (Neut)
Useful in alkalization of urine to prevent acute myoglobinuric renal failure; titrate dose to increase pH to 7.45-7.55; onset of action is within minutes and lasts approximately 15-30 min; monitor blood pH to avoid excess alkalosis. Maintain normal serum potassium level because urinary alkalinization impossible if patient is hypokalemic.
Osmotic diuretics
Mannitol (Osmitrol)
Alternative diuretic used when urine output is inadequate despite aggressive fluid therapy.
Initially assess for adequate renal function in adults by administering test dose of 200 mg/kg IV over 3-5 min; should produce urine flow of at least 30-50 mL/h of urine over 2-3 h.
In children, assess for adequate renal function by administering test dose of 200 mg/kg IV over 3-5 min; should produce urine flow of at least 1 mL/h over 1-3 h.
Antihypertensives
Phentolamine (Regitine)
Alpha1 and alpha2 adrenergic blocking agent that blocks circulating epinephrine and norepinephrine action, reducing hypertension that results from catecholamine effects on alpha-receptors.
Sodium nitroprusside (Nitropress)
Produces vasodilation and increases inotropic activity of heart; at higher dosages, may exacerbate myocardial ischemia by increasing heart rate.
Nitroglycerin (Nitro-Bid, Nitrostat, Deponit)
Decreases coronary vasospasm, which increases coronary blood flow; in addition, induces vessel dilatation, decreasing cardiac workload.
Diuretic
Furosemide (Lasix)
Increases excretion of water by interfering with chloride-binding cotransport system, which, in turn, inhibits sodium and chloride reabsorption in ascending loop of Henle and distal renal tubule; potent vasodilator of medullary vessels serving to wash out concentration gradient of countercurrent system, resulting in marked diuresis.
GI decontamination
Activated charcoal (Liqui-Char, Actidose-Aqua)
Network of pores present in activated charcoal adsorbs 100-1000 mg of drug per gram of charcoal; does not dissolve in water; for maximum effect, administer within 30 min of poison ingestion; may administer as aqueous suspension or combined with cathartic (usually sorbitol 70%) and with presence of active bowel sounds; may need to be repeated (without cathartic) to adsorb large pill masses or drug packages.
Glucose supplement
Dextrose (Glucose-D)
Monosaccharide, absorbed from intestine and distributed, stored, and used by tissues. Parenterally injected dextrose is used in patients unable to obtain adequate oral intake; direct oral absorption results in rapid increase of blood glucose concentrations. Effective in small doses; no evidence indicates that it may cause toxicity; concentrated infusions provide higher amounts of glucose and increased caloric intake with minimum fluid volume.
Vitamin supplementation
Thiamine (Vitamin B-1)
Supplementation ensures adequate cofactor for maintenance of cellular aerobic respiration. CNS depletion of thiamine may result in Wernicke encephalopathy.
