Article Figures & Tables
Figures
- Figure 1:
The chemical structures of paramethoxymethamphetamine (PMMA) and methylenedioxymethamphetamine (MDMA or “ecstasy”).
- Figure 2:
Antemortem end-organ dysfunction based on clinical findings and investigations of 13 of the 17 patients who died in hospital. Data were missing for 4 patients who were pronounced dead shortly after arrival in the emergency department [no antemortem investigations performed].
Tables
- Table 1: Summary of 27 deaths associated with the use of paramethoxymethamphetamine (PMMA) in Alberta and British Columbia, June 2011 to April 2012
Case Location and circumstances
around presentation and deathDrug(s) believed to have been consumed Postmortem findings 1 Took drugs at home; became unwell, friend called 911; died in ER Ecstasy Pulmonary edema, CAD 2 Took ecstasy alone; found 9 hours later; died in ER after unsuccessful resuscitation Ecstasy Rapid rigor mortis 3 Took pills alone, felt unwell and self-presented to ER; died in ICU Ecstasy Cerebral edema, pulmonary edema 4 Took ecstasy with friends; became unresponsive; transported to ER in private vehicle; died in ICU Ecstasy Cerebral edema, ascites, pleural effusion 5 At house party after taking drugs; became unresponsive; transported to hospital via EMS; died in ICU Ecstasy Rhabdomyolysis 6 Found unresponsive at house party; transported to hospital via EMS; had cardiac arrest, died in ICU Ecstasy, alcohol No autopsy 7 At house party; found unresponsive after last seen 1.5 hours earlier; transported to hospital via EMS, had cardiac arrest; died in ICU Ecstasy No autopsy 8 Found dead in bed at home Unknown Trivial soft-tissue abrasions 9 At house party with friends; became unwell; cardiac arrest after intubation with EMS; died in ICU 8 tabs of ecstasy Lung congestion, patchy pneumonia 10 Watching live performance; became unwell; cardiac arrest with EMS; died in ER after unsuccessful resuscitation 1–2 g of MDMA, cocaine Cardiomegaly, spleen congestion 11 At nightclub; became unwell; transported to ER in private vehicle; died in ICU 6 tablets of MDMA, hallucinogenic mushrooms, LSD No autopsy 12 Found dead at home Unknown Pulmonary congestion, cerebral edema, mottled myocardium, cardiomegaly 13 Friend noticed patient acting abnormally; transported to hospital in private vehicle after seizure; died in ER 2 snorts of MDMA/ecstasy powder Congestion of heart, lungs and liver 14 Took drugs at house party; found unconscious outside at nearby property; died in ER after unsuccessful resuscitation Unknown amount of white powder believed to be ecstasy Congestion of heart, lungs, liver and spleen, cerebral edema 15 At a bar with friends; that night at home had a witnessed seizure, followed by cardiac arrest; pronounced dead upon EMS arrival Unknown Pulmonary edema, congestion of heart, liver and spleen, cerebral edema 16 Took 2 doses of ecstasy at bar; began acting strange upon return home with friends; had seizure en route to hospital with EMS, and cardiac arrest in ER; died in ER after unsuccessful resuscitation 2 pills of ecstasy Pulmonary edema, kidney and spleen congestion, interstitial hemorrhage in heart 17 At home with friends drinking and taking drugs; found dead the next morning Cocaine, MDMA, alcohol Fatty liver, unremarkable post mortem 18 At a house party; felt unwell, called 911; cardiac arrest soon after EMS arrival; died in ER after unsuccessful resuscitation Unknown white powder snorted Rib and sternal fractures, pulmonary edema, advanced cirrhosis, enlarged spleen 19 Took MDMA powder the night before; felt unwell; found unresponsive the next afternoon; pronounced dead with EMS 1.5 g of MDMA rolled in paper and ingested Cerebral and pulmonary edema 20 Took drugs throughout the night at home; had cardiac arrest; died in ER after unsuccessful resuscitation MDMA, cocaine Pulmonary congestion, cardiomegaly, nephrosclerosis 21 At party the night before with friends; found dead at home the next day Ecstasy, cocaine Edema and congestion of lungs, liver, spleen and kidneys 22 Last seen 3 days earlier; police/EMS attended; pronounced dead at the scene Unknown Pulmonary congestion 23 Partying with friends the night before; no history of drug use; found dead the next day Unknown Pulmonary edema 24 Last seen 3 days prior. Police/EMS attended, dead on scene. Cocaine, alcohol Congestion of lung, liver, spleen and kidneys 25 At house party; took multiple doses of MDMA through the night by snorting and ingestion; became confused and unresponsive; friends called 911; died in ER after unsuccessful resuscitation 0.5 g of MDMA Pulmonary congestion 26 At party with friends; EMS called; cardiac arrest after intubation; resuscitated in ER, died in ICU 7 tabs of MDMA No autopsy 27 At concert; took drugs and alcohol; pronounced dead at home with EMS MDMA, cocaine, alcohol No autopsy Note: CAD = coronary artery disease, EMS = emergency medical services, ER = emergency department, ICU = intensive care unit, LSD = lysergic acid diethylamide, MDMA = methylenedioxymethamphetamine.
- Table 2: Results of antemortem laboratory investigations for patients transported to hospital (n = 13/17)*
Investigation Level, median (range) Normal range† Peak potassium, mmol/L 7.0 (4.4–12.5) 3.5–5.1 Peak creatinine, mmol/L 214 (146–1127) 50–110 Peak AST, U/L 2944 (116–5124) 7–40 Peak creatinine kinase, U/L 8200 (1952–237 960) 38–215 Lowest recorded glucose, mmol/L 1.9 (0.4–17.1) 3.9–6.1 Note: AST = aspartate transaminase. *Data missing for 4 patients; they were pronounced dead shortly after arrival to the emergency department (no antemortem investigations). †Normal values were obtained from the Royal College of Physicians and Surgeons of Canada. (17)
- Table 3: Therapies provided by emergency medical services or in hospital for patients transported to hospital (n = 9/17)*
Therapy No. (%) of patients Intubation 9 (100) Paralysis 6 (67) Sedation 5 (56) Cooling Ice packs 4 (44) Cooled intravenous fluid 2 (22) Cyproheptadine 1 (11) Cooling blanket 1 (11) Cooling catheter 1 (11) *Data missing for 8 patients.
Case Specimen type Toxin, mg/L Other findings* PMMA PMA MDMA MDA MAMP AMP Cocaine BE 1 Postmortem blood† 1.6 0.17 2.3 0.12 0.84 0.024 ND ND Lidocaine 2 Postmortem blood† NSQ NSQ 3.9 0.12 ND ND 0.38 3.9 PMMA vitreous 0.69 mg/L; MDMA vitreous 1.4 mg/L; cannabinoids 3 Antemortem blood† 1.2 0.093 0.99 0.036 ND ND ND 0.32 4 Antemortem blood† 1.6 0.098 0.52 0.021 ND ND ND ND Lorazepam 5 Postmortem blood† 1.8 ND 0.6 ND ND ND ND ND Morphine, lidocaine, cannabinoids 6 Antemortem blood† 0.11 0.023 0.14 0.015 ND ND ND ND Midazolam, temazepam, rocuronium metabolite, acetaminophen 7 Antemortem blood† URP URP 0.32 ND ND ND ND ND 8 Postmortem IVC blood 3.33 0.42 3.09 0.17 2.28 0.07 ND ND Dextromethorphan 0.66 mg/L, acetaminophen 18.2 mg/L, ketamine, oxycodone 9 Antemortem serum† 0.94 0.07 0.09 Trace 0.3 Trace ND ND Postmortem IVC blood 0.14 Trace Trace Trace 0.11 Trace ND ND 10 Antemortem blood† 2.28 0.1 0.31 Trace 0.75 Trace ND 0.19 Postmortem femoral blood 4.41 0.25 0.6 Trace 1.47 Trace Trace 0.26 11 Antemortem blood† 0.44 0.08 Trace Trace 0.18 Trace TNP TNP Drug screen not performed (limited specimen) 12 Postmortem IVC blood 3.74 0.11 1.64 Trace ND ND ND ND Ethanol 30 mg/100 mL 13 Antemortem blood† 1.25 0.07 0.11 Trace 0.35 Trace ND 0.11 Postmortem IVC blood 2.67 0.18 0.26 Trace 0.8 Trace ND 0.17 14 Postmortem IVC blood 2.7 0.12 0.29 Trace 0.86 Trace ND ND Postmortem central blood 4.35 0.18 0.43 Trace 1.28 0.05 ND ND 15 Postmortem IVC blood 2.97 0.08 0.32 Trace ND ND 0.04 0.3 Acetaminophen 10.6 mg/L, codeine 0.07 mg/L, atropine 16 Postmortem IVC blood 1.67 0.15 0.27 Trace 0.63 Trace Trace 0.2 Oxycodone (trace), delta-9- tetrahydrocannabinol 2.3 ng/mL, carboxy- tetrahydrocannabinol 11.8 ng/mL 17 Postmortem IVC blood 4.88 0.22 1.12 0.04 1.78 0.06 0.08 0.84 Levamisole, phenacetin 18 Postmortem femoral blood 3.56 0.33 1.7 0.12 Trace ND ND 0.67 Benzylpiperazine 19 Postmortem central blood 0.65 0.06 2.58 0.06 ND ND ND ND Ethanol 10 mg/100 ml. 20 Postmortem femoral blood 15.7 0.75 0.65 Trace ND ND ND ND Diphenhydramine 21 Postmortem femoral blood 6.19 0.51 0.26 Trace ND ND ND ND Dextromethorphan 22 Postmortem iliac blood 5.36 1.08 0.6 0.05 1.45 0.1 Trace 0.11 Oxycodone 2.01 mg/L, ibuprofen 23 Postmortem femoral blood 6.34 0.23 0.34 Trace ND ND Trace 1.16 Benzylpiperazine 1.65 mg/L, TFMPP 0.47 mg/L, ketamine, levamisole 24 Postmortem femoral blood 3.58 0.23 0.16 Trace ND ND ND ND Benzylpiperazine 1.00 mg/L, TFMPP 0.15 mg/L 25 Antemortem blood† 1.6 0.1 0.14 Trace 0.47 Trace Trace 1.09 Ketamine 0.71 mg/L, midazolam 26 Antemortem blood† 3.27 0.09 0.16 Trace ND ND Trace 0.53 Postmortem iliac blood 3.83 0.14 0.19 Trace ND ND Trace 0.55 27 Postmortem iliac blood 2.17 0.08 1 Trace ND ND 0.05 0.46 Ethanol 10 mg/100 mL, naproxen Note: AMP = amphetamine, BE = benzoylecgonine (metabolite of cocaine), IVC = inferior vena cava, MDA = methylenedioxyamphetamine, MAMP = methamphetamine, ND = none detected (below level of detection), NSQ = not sufficient quantities, PMA = paramethoxyamphetamine, TFMPP = trifluoromethylphenylpiperazine , trace = detected but below level of quantitation, TNP = test not performed, URP = urine positive for drug but insufficient antemortem blood available to permit quantitation. *Unless otherwise specified, drugs in this column were not quantitated. †Not otherwise specified.
Blood sample Concentration, mg/L, median (range) Antemortem blood 1.43 (0.11–3.27) Postmortem IVC and central blood 2.84 (0.14–4.88) Postmortem femoral and iliac blood 4.41 (2.17–15.7) Note: IVC = inferior vena cava, PMMA = paramethoxymethamphetamine. *Insufficient blood sample for quantitation in case 2; antemortem urine test positive in case 7, but no postmortem blood test performed.
In this issue
Article tools
Respond to this article
