Re: What to do in case of an ecstasy overdose?
found an article on erowid relating to this:
Survival After Massive Ecstasy Overdose.
by S Ramcharan, PL Meenhorst, JMMB Otten, CHW Koks, D de Boer, RAA Maes and
Introduction: The toxicity profile of the amphetamine derivative
3,4-methylenedioxymethamphetamine (MDMA, "Ecstasy") is well known. This designer drug is
usually taken at "house parties" and may cause severe complications, sometimes leading to
death, even when taken in relatively small units (1 or 2 tablets). Up to now, only a few cases of
survival after ingestion of an overdose of Ecstasy have been described. In most cases the users
developed hyperthermia, disseminated intravascular coagulation, rhabdomyolysis, and renal
failure. Case Reoort: We describe a man who, after ingesting SO tablets of Ecstasy (in
combination with oxazepam and alcohol) at home, recovered within 2 days. Presenting features
were unconsciousness, apnea, and convulsions. It is suggested that in most cases severe
3,4-methylenedioxymethamphetamine toxicity results from an interaction between direct
pharmacological effects of the drug and the prevailing environmental conditions (high ambient
temperature, dancing in trance, little fluid intake.
3,4-Methylenedioxymethamphetamine (MDMA, "Ecstasy") is an amphetamine derivative that has become increasingly
popular as a recreational drug in recent years. Part of its popularity may lie in the belief that MDMA is relatively
harmless.[1,2] The use of MDMA makes people feel euphoric, loquacious, and closer to other individuals; some call it the
"love drug." It is often taken at "house parties" as mood enhancer.[3,4] It has, however, many adverse effects, such as
loss of appetite, trismus or bruxism (grinding of the teeth), nausea, muscle aches or stiffness, ataxia, sweating,
tachycardia, and hypertension. MDMA is also known to damage brain serotonin neurons. There has been a recent
increase in cases of severe toxicity following recreational misuse of relatively small amounts (1 or 2 tablets) of MDMA.
Complications have included fulminant hyperthermia, convulsions, disseminated intravascular coagulation,
rhabdomyolysis, acute renal failure, cardiac arrhythmias, hepatitis, and even liver failure.[6-8]
This study describes a patient who attempted suicide by ingesting 50 tablets of Ecstasy at home and had an uneventful
recovery within 2 days.
A 30-year-old man was admitted to the Emergency Department of our hospital after being found unconscious, apneic, and
with symmetrical convulsions at home. He confirmed later, after recovery, to have taken 50 tablets of Ecstasy, 10 tablets
of oxazepam 10 mg, and 5 units of alcohol over a period of 4 to 5 hours. He was intubated and ventilated and transported
to our hospital.
On admission, he was still comatose and had convulsions. Other significant findings on physical examination included a
body core temperature 38.7 [degrees] C, blood pressure 135/85 mm Hg, and a regular pulse rate 120/min. His pupils
were dilated and did not react to light. Relevant laboratory findings on admission, including arterial blood gas analysis,
were pH 7.20, P[O.sub.2] 475.0 mm Hg (63.2 kPa), P[CO.sub.2] 59.0 mm Hg (7.8 kPa), [O.sub.2] sat 99.9%, [HCO.sub.3]
[sup.-]22.3 mmol/L. Apart from a serum calcium of 2.18 mmol/L (albumin 44 g/L) and CPK of 79 U/L (upper limit 70 U/L),
all laboratory findings were within the normal range. A chest X ray showed no abnormalities and the ECG showed sinus
tachycardia. The symptomatology was an expected manifestation of an Ecstasy or amphetamine intoxication. The patient
was ventilated, extensive gastric lavage (20 L) was performed, and activated charcoal was instilled into his stomach. After
intravenous administration of dantrolene 1 mg/kg body weight (total dose 80 mg), his temperature dropped to 38.0
[degrees] C. Because he did not respond sufficiently to clonazepam 1 mg, pancuronium bromide 6 mg, a muscle relaxant,
was administered following which his convulsions subsided. After a few hours, arterial blood gases returned to normal.
Within 2 days, he recovered completely with the exception of an increased CPK, thought due to convulsions. No other
laboratory abnormalities were noted and 3 days after admission, he was discharged.
Several urine and serum samples and gastric lavage fluid were analyzed. A fluorescence polarization immunoassay
(FPIA) screening of the urine samples for amphetamines and derivatives was performed in our hospital using a
TDxFLx[R] analyzer (Abbott). A quantitative GC/MS confirmation for MDMA and MDA (3,4-methylenedioxyamphetamine,
the main metabolite of MDMA) in the urine samples was then done. After isolation of the amphetamines by liquid-liquid
extraction and derivatization with fluosol DA, GC/MS analysis was performed. (RS)-propylhexedrine was used as internal
standard. Table 1 shows the results of both the immunoassay screening on amphetamines and derivatives in general and
the quantitative GC/MS confirmation for MDMA and MDA in particular.
Results of FPIA Screening and GC/MS Analysis
Time After Sample FPIA Results
4 urine positive
36 urine positive
60 urine positive
Time After GC/MS Results
Ingestion Concentration of MDMA Concentration of MDA
(hours) Enantiomers (mg/L) Enantiomers (mg/L)
R-(-) S-(+) R-(-) S-(+)
4 44 42 nd 0.4
70 72 nd nd
36 36 17 3 7
60 18 10 5 4
0.8 0.2 nd nd
na: not analyzed; no material available; nd: not detected; limit of detection is 0.005 mg/L.
MDMA is well absorbed from the gastrointestinal tract after oral ingestion, and peak serum levels occur within 1 to 3
hours. The drug is highly lipid soluble and readily crosses the blood-brain barrier. Protein binding and volume of
distribution vary widely. MDMA undergoes extensive hepatic metabolism with the production of MDA which also exhibits
pharmacologic activity. Unchanged drug and metabolite are then excreted into the urine. The elimination half-life of
MDMA is 6 to 7 hours. Studies on tissue distribution show the highest concentrations of both MDMA and MDA in liver and
In our case, we observed high MDMA levels in the gastric lavage. Logically no MDA is detected in the gastric lavage since
the drug is metabolized in the liver. The gastric fluid contained almost equal quantities of R-(-)-MDMA and S-(+)-MDMA
indicating that the Ecstasy tablets contained equal amounts of the enantiomers. The gastric lavage (20 L) was effective
with the removal of 2,800 mg MDMA. On the second day, the urine samples showed the expected decrease in MDMA
concentration with a further decrease on the next day. The third day, a serum specimen revealed low levels of MDMA
while MDA was not detected. R-(-)-MDMA serum level was higher than the level of the S-(+) enantiomer. The
N-demethylation pathway for MDMA is enantioselective as demonstrated in rats and mice. If this finding can be
extrapolated to humans, it may explain the enantiomeric profiles of MDMA and its N-demethylated metabolite MDA.
MDMA has a rapid onset of action of approximately 1/2 hour. Users describe 3 phases: an initial period of disorientation,
followed by a rush during which the user experiences tingling and may exhibit spasmodic jerking motions, and finally, a
period of "happy sociability." Generally, MDMA’s effects wear off in 4 to 6 hours; however, confusion, depression, and
anxiety have been reported by some users to last for several weeks after a single dose. The side effects of MDMA
range from mild to severe and may even be fatal. Since the drug is illegally produced, tablet dosages vary, but it is
generally thought that each tablet contains at least 50 to 150 mg of MDMA. The literature describes cases in which
patients die after ingestion of 1 to 3 Ecstasy tablets, with serum levels ranging from approximately 0.1 to 0.4 mg/L. In
our patient, these serum MDMA levels were reached 60 hours after Ecstasy ingestion (Table 1) and indicate the severity
of this intoxication. Two cases of massive overdose have been described adequately. In one case, the patient ingested 42
tablets of Ecstasy at home (plasma MDMA 7.72 mg/L) and showed no symptoms other than a "hangover" with
tachycardia and hypertension. Another patient ingested an overdose of 40 Ecstasy tablets but developed no significant
complications. Consequently, there is no firm estimate of a dose at which toxicity is likely to occur, and the relationship
between the dose of MDMA and the production and severity of complications is not straightforward. MDMA is believed
to act through at least 3 neurotransmitter pathways: the serotoninergic pathway is principally affected, which would
account for the more pronounced effect on mood, anxiety, cognition and impulse control. The drug also influences
dopaminergic and noradrenergic systems. Serotonin plays a major role in thermoregulation and interference with this
mechanism is believed to be the cause of the hyperthermia which arises as a complication of MDMA misuse (resembling
a serotonin syndrome). Stimulation of the noradrenergic system probably also contributes to hyperthermia. In fatal
cases, death is usually due to severe hyperthermia (heatstroke) accompanied by disseminated intravascular coagulation,
rhabdomyolysis, and acute renal failure.[6,17] It is suggested that the combination of the drug and the circumstances in
which it is taken are important in the mechanism of its toxicity. Most of the serious cases that are mentioned were
among people at crowded parties or clubs. At such venues, sustained physical activity (which may itself be an effect of the
drug), a high ambient temperature, poor ventilation, and inadequate fluid replacement could all reduce heat-loss and
potentiate a direct effect of the drug on thermoregulatory mechanisms, leading to fulminant hyperthermia.[3,6,15,18,19]
Under normal conditions, intracellular calcium increases with muscular contraction and decreases with relaxation. MDMA,
through some unknown mechanism, possibly causes intracellular calcium ion increase with associated muscular
contraction, and prevents decrease and relaxation. This results in erratic, uncontrolled, constant muscular contractions
that require larger amounts of oxygen and produce large volumes of carbon dioxide, lactic acid, energy, and heat. A
profound acidosis will change membrane permeability, resulting in the release of calcium, potassium, creatinine
phosphokinase, and myoglobin from muscle cells. The features of an intoxication are hyperthermia, muscle rigidity,
profound respiratory and metabolic acidosis, and hyperkalemia. At this point, the acidosis and the electrolyte disturbances
are sufficient to cause fatal cardiac arrhythmias. Individuals who use Ecstasy while engaging in strenuous physical
activity can easily become dehydrated. In cases of severe dehydration, development of cerebral thrombosis is
possible. At house parties, alcohol consumption may also enhance the pharmacological effects of MDMA. Drug
agencies are aware of the risk of hyperthermia and advise those who use the drug to wear loose clothing, to drink
adequately in order to facilitate thermoregulation, and to stop dancing when feeling exhausted. Some club owners have
provided "chillout" rooms with seating and air conditioning to help cooling.[5,17]
The fact that our patient survived his suicidal attempt might be ascribed to the effective gastric lavage but possibly also to
the ambient circumstances after ingestion. He took the drug at home, in a quiet setting where none of the conditions
necessary to induce or enhance toxicity were present. We think that this case lends further weight to the hypothesis that
MDMA toxicity may be increased by an interaction of direct pharmacological effects of the drug and the prevailing
environmental conditions at administration. Other factors (e.g., immune mechanisms, genetic variants of CYP2D6,
idiosyncrasy) can not be excluded. Immediate large-volume gastric lavage may still be beneficial 4 hours after intake.
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S Ramcharan; PL Meenhorst; JMMB Otten; CHW Koks; D de Boer; RAA Maes; JH Beijnen
Slotervaart Hospital, Amsterdam (SR, PLM, JMMBO, CHWK, JHB); Utrecht University, Utrecht (DdB, RAAM), The
Correspondence: Prof. Dr. J. H. Beijnen, Department of Pharmacy and Pharmacology, The Netherlands Cancer
Institute/Slotervaart Hospital, Louwesweg 6, 1066 EC Amsterdam, The Netherlands. Tel: 31/20-512-4481; Fax:
31/20-512-4753; E-mail: APJBY@SLZ.NL
Journal of Toxicology: Clinical Toxicology Dec 1998 v36 i7 p727(1) Page 4
Anecdotally, swim can say that he has seen some of his friends overdo it. If they were responsive they were given cool water to sip on, and put in a lukewarm shower while being monitored. After a few hours they came out of it. Some even went from breathing heavily and sweating profusely, just generally looking like shit to coming out being in a great mood. If anyone is ever unresponsive the best idea is to call 911.
The problem with ecstasy pills sometimes is that there can be any number of chemicals in an "ecstasy" tablet. Swim himself has never overdosed on mdma but has definitely had adverse reactions to some pills (like being on the drug was torture but the comedown
felt good). Bastards made those...