Drug related adverse incidents at music festivals and rave parties
Over the past years there has been an increase in the incidence of drug related adverse incidents and unfortunately also the worst possible outcome the deaths of young dance party revellers.
There is no doubt that not taking drugs is the answer however as recently reported a very high percentage of revellers attending these parties are using drugs with MDMA being the most commonly used.
A better treatment availability at the events and drug testing are all being looked at but the absence of better education in first responder (their friends) recognition and what they can do to reduce the chance of serious adverse reactions while waiting for the onsite medical teams to attend is lacking.
The following covers some of the preventive measures first aid treatments and other information on how to help reduce the incidence of serious adverse effects of MDMA.
The effects of ecstasy can start with an hour and typically last up to about six hours. Some effects may continue for up to 32 hours.
The effects on your body can include.
Muscle aches and pains
Increased body temperature (hyperthermia)
Drinking excessive amounts of water (can lead to coma and death)
Heat related injury and recreational drugs
Hyperthermia is the loss of the ability of the body to regulate normal body core temperature and as a result hyperthermia can produce severe or even fatal changes in organ health. Also, research has shown that MDMA (more commonly known as Ecstasy or Molly) and other Amphetamines is linked to increased chances of experiencing this dangerous increase In temperature.
Heat illness is the most common cause of morbidity and mortality from MDMA ingestion for those presenting to medical staff; however, the MDMA is not the only factor which caused the illnesses. MDMA disrupts the body’s natural thermoregulatory mechanisms with a ‘normal’ dose increasing the core temperature by up to 1°C. MDMA ingestion in conjunction with typical activities undertaken at dance festivals; increased consumption of alcoholic and caffeinated drinks coupled with decreased consumption of water & electrolyte drinks and very high levels of aerobic activity for extended periods, are all significant risk factors for heat illness. Therefore, with the many of these risk factors being present at raves/ dance parties, it is critical safe work practices and medical protocols are established for these events. Changing the environment if WBGT (wet-bulb globe temperature) is high by using fans, water sprays etc, mitigating personal risk by providing easy access to water and electrolytes, increased medical staff and airconditioned quiet rooms. One study concluded that even a moderate dose of the drug can trigger lethal spikes in brain temperature when consumed in warm or hot environments 
It is Important that the contributing factors also be monitored during the event:
Deploy extra on site EMTs/Medics with the crowd with appropriate cooling and resuscitation equipment when the WBGT readings (see chart below) are approaching a danger level;
Advise of the risk of energy drinks and MDMA combination and encourage water consumption;
Have break periods in the entertainment and encourage check a friend, rehydrate and cool down;
Increase water cooling spray points over the crowd.
Friends and Music lovers
take with you some instant ice packs, water for cooling and a hand fan.
Have sodium containing electrolyte drinks available as just drinking water in hot sweaty conditions increases the risks (see Paradoxically, too much water can also kill)
Keep an eye on body temperature use a thermometer if you or one of your friends is not looking good. Being over 40C can be fatal if not treated early.
If body temperature is increasing rapidly cool down and call for help don’t delay..
Drug related SEVERE HYPERTHERMIA risk can be elevated with:
• Physical exercise, dancing etc;
• WGBT over 29°C;
• High or multiple drug dosages;
• Multiple different drugs used;
• consumption of caffeine containing drinks.
Caffeine may amplify the effects of neurotoxic drugs and information should be given to participants that energy drinks, Cola drinks and coffee (containing caffeine) may increase adverse/toxic events in combination with drugs including MDMA. Consumption of caffeine profoundly enhances the acute toxicity of MDMA in animal and human studies, as manifested by high core body temperature, tachycardia and increased mortality. In addition, co-administration of caffeine enhances the long-term serotonergic neurotoxicity induced by MDMA [2-6].
Although caffeine alone failed to alter body temperature, it potentiated MDMA-induced hyperthermia. This association also significantly increased MDMA lethality (from 22% to 34%). Also, the effect on CYP1A2 one of the cytochrome P450 superfamily of enzymes is doubled in females 40% compared to males 20% .
Paradoxically, too much water can also kill.
Studies involving athletes found that drinking too much water during exercise can cause over-hydration and as a result can lead to exercise-associated hyponatremia. This occurs when athletes drink even when they are not thirsty, and the sodium content of blood is diluted to abnormally low levels (dilutional hyponatremia).
Drinking too much water when profusely sweating over a prolonged exercise period can also overwhelm the kidney's compensation mechanism and reduce the body's ability to remove water. Taking MDMA and other drugs and dancing in hot weather and drinking lots of water increases the risk of low sodium (hyponatremia) and this can be fatal .
MDMA can cause life‐threatening hyponatraemic encephalopathy when accompanied by excessive fluid ingestion. The mechanism involves inappropriate secretion of antidiuretic hormone leading to either an excess or insufficient urination, further exacerbating the adverse effects of MDMA and caffeine.
Awareness of the danger of hyperthermia among users of MDMA leading to the practice of drinking large volumes of water to prevent the compounding effect of dehydration, venues have provided ‘chill-out’ areas with free water. However, several deaths in Ecstasy users have been reported resulting from dilutional hyponatraemia and consequent cerebral oedema
One study found that 3% of males, but no less than 25% of females attending a rave party and using MDMA developed mild hyponatraemia during the event” . Furthermore, female patrons are significantly more likely to develop hyponatraemia and also at increased risk of developing severe symptomatic or asymptomatic hyponatraemia. Hyponatraemic encephalopathy is a complication of MDMA use with significant morbidity and mortality; many of the reported cases exhibited serum sodium ≤130 are females between 15 and 30 years of age, with a greater than 50% mortality rate found. The clinical signs of Hyponatraemic encephalopathy secondary to MDMA ingestion include: nausea, vomiting, headaches, brainstem herniation eventually leading to cardiorespiratory arrest and death[9, 10]. Hyponatraemic encephalopathy also presents more often in female athletes compared to their male counterparts with the competitors from the New Zealand Ironman triathlon demonstrating 45% vs 14% respectively .
Hyponatremia signs and symptoms may include :
Nausea and vomiting.
Loss of energy, drowsiness and fatigue.
Headache, restlessness and irritability.
Muscle weakness, spasms or cramps.
It is important that a complete set of observations (vital signs) and pre-incident drinking, drug and food intake be gathered. In certain situations, this may have to be given by friends or bystanders, as the patient may not be able to.
If the above symptoms are associated with large quantities of water that has been consumed in combination with little food intake and MDMA, dilutional hyponatremia can be suspected and a urine dip stick test (if this can be appropriately obtained) may help confirm this. If dilutional hyponatremia is suspected escalate casualty to expert medical treatment ASAP and if associated with an increase in body temperature 39°C plus start aggressive cooling immediately.
Despite the clinical importance, of monitoring serum and urine sodium are rarely monitored; this may be due to the fact that 24hr urine collection has major shortcomings. A new technique which is proving easy and cost effective is a urine dipstick which can be done bedside .
The incidence of Exercise-Associated Hyponatremia (EAH) continues to spread into a wider variety of sporting activities and dance/rave parties and cause unnecessary deaths in otherwise healthy individuals. This is where excessive sweating causes loss of sodium, further exacerbated by over consumption of water, especially when in conjunction with MDMA or other illicit drug use.
The key treatment for EAH is a hypertonic saline infusion and oral rehydration as tolerated; oral rehydration must be with 100mL of 3% saline mixed with a sweetener (low calorie preferred). If patient is unable to tolerate oral rehydration or has impaired swallowing reflex IV infusion of 3% saline at 1-2mL/kg/hr will be required, recommended at 100mL boluses and monitored closely for accidental hypernatremia . Whilst administration of 0.9% (normal) saline (154 mEq/L of sodium) would appear to assist in the normalisation of sodium levels in a EAH, however using 3% saline at 1mg/kg increases sodium levels by approximately 1 mEq/L, therefore requires less fluid, decreasing the likelihood of overhydration and exacerbation of the EAH symptoms .
To avoid EAH, drinking to thirst only is recommended both during and post exercise, especially when the exercise is in high temperatures or extended duration. Furthermore, aggressive cooling is essential if body temperature is raised and urgent transport to hospital is required by calling 000 [16, 17].
“…while sodium ingestion during a race may reduce the fall in blood sodium concentrations, it cannot prevent Hyponatremia in the setting of excessive fluid intake. It is the amount of fluid ingested rather than the amount of sodium ingested during exercise that drives the final blood sodium concentrations. Sodium-containing sports drinks, which are hypotonic, will not prevent EAH…” 
Administration of isotonic or hypotonic (low sodium) fluids are not advised where EAH is confirmed unless it is Hypovolemic hyponatremia.
There are many good sports electrolyte replacements available that may help reduce sodium loss. Always carry and use these and have them readily available and don’t overdo the water drink to thirst and stay out of the sun and take time out to cool down have some instant ice/cold packs with you as well.
Heat Injury and Heat Stroke
Heat exhaustion is a serious condition that can develop into heat stroke and needs to be treated seriously and quickly. If you start to suffer the symptoms of heat injury it is important to slow activity and cool down, you can’t run or exercise through heat injury and progression can result in heat stroke which is a serious potentially fatal medical emergency.
Clinical reports and animal studies indicate that hyperthermia is a primary effect of psychostimulant drugs (MDMA) and can occur independently of seizures or increased motor activity .
May present as heat stroke (severe), heat exhaustion (moderate) or heat
Warning signs hyperthermia may include:
Temperature 37.5 to 38C
●Pale and sweating
●Rapid heart rate
●Muscle cramps, weakness
Clinical sings for progressive moderate to severe hyperthermia include;
• Elevated Temperature from 38.1°C – 38.9°C moderate and over 39C severe
• may be confused and mildly agitated
• Increased heart rate >100 (Tachycardia)
• Systolic BP over 140
• Mild confusion
• Temperature >39°C can also be associated with aggression, confusion or agitation
• If not appropriately treated early and escalated to advanced medical facility multi-organ failure can progress rapidly.
Heat stroke is a life-threatening emergency. It occurs when the body’s natural thermoregulatory system is unable to prevent the temperature rising rapidly.
Heat stroke presents with similar clinical signs as heat exhaustion, with the addition of dry, hot & red skin, confusion, staggering walk, collapse, seizures and unconsciousness . Heat stroke occurs at a core body temperature at or above 39–41ºC. It usually results from a prolonged exposure to extreme heat or physical activity with drug use during extreme heat.
Morbidity and Mortality (death) increases significantly when cooling is delayed. The combination of atomised tepid water from a spray bottle and standing fans cools at a comparable rate to ice bath immersion and is much more amenable in field applications.
FAN and water spray were significantly more effective in reducing temperature in the first 20 min of cooling when compared with the ICE and chilled IV Saline and would be suitable for first aid application in a field setting during transportation to adequate medical facilities .
It was previously thought immersing young fit patient’s with exertional heat stroke in ice-water is considered the best practice after studies showing very low mortality rates; with older patients suffering from non-exertional heat stoke faring better from evaporative cooling using fans. Additionally, administration of chilled IV fluids and placing icepacks on the patient can assist in the active cooling process and that ice packs are especially useful when applied to the neck, groin and armpits. However, recent studies have shown that use of chilled IV fluid, icepacks and similar techniques are not best practice and are not not recommended .
Heat injury and heat stroke treatment
Heat Stroke is a medical emergency and the casualty MUST be cooled quickly without any delay and send for help by calling 000
●Loosen or remove clothing get them out of the sun or off a hot road and wet skin and hair whole body with water and fan (use water injection fan cooling equipment).
●Send for expert help (000) call the for Medics/first aid at the event.
●Continue cooling with cooled water (use our high-speed water injecting fan) until medical help arrives.
●augment this cooling with; place cold, cooled wet towels over body and cold packs under arms, on sides of neck, in groin change regularly with fresh cooled equipment with continued fanning
●Consider the use of cold-water immersion (CWI) at or less than 10°C if available but don’t delay other active cooling while arranging one [21, 22].
The use of approximately 10°C CWI is logistically manageable and empirically supported
●Only give sips of cool water.
●Giving electrolytes such as hydrolyte is even better if available, as large quantities of water can cause vomiting and stomach cramps DRINK SLOWLY
●If unconscious place on side and manage airway
● Do CPR if not breathing properly and unresponsive.
Do an in-situ set of vital signs’ including; temp, BP, SpO2, PR, BR, BSL, Sodium level if possible
CARPA states Do not
● Do not use ice bath in field
1. Shuts down blood flow to skin and slows cooling
2. Makes monitoring and treatment harder
● Do not give medicines to lower temp — antipyretics (eg paracetamol)
●At many Dance music and rave events over drinking water is common, obtain history as to fluid intake.
●isotonic IV infusion should only be administered to hyperthermic and dehydrated individuals and should not be considered for individuals that are hyperhydrated and/or hyponatremic  (SEE dilutional hyponatremia)
Prevention is best;
●Keep well hydrated
●Wear a ventilated hat or cap
●Wear clothes that allow sweat to evaporate and cool the body
●If you start to feel the symptoms STOP and cool down. You can’t run through heat injury or heat stroke.
Dehydration is when fluid loss or use exceeds intake for an extended period, resulting in the body being unable to function properly, especially those involved in body temperature regulation.
Infant or young child
Dry mouth and tongue
No tears when crying
No wet diapers for three hours
Sunken eyes, cheeks
Sunken soft spot on top of skull
Listlessness or irritability
Less frequent urination
If heat injury is associated with dehydration
Despite no statistically significant performance differences between DRINK and IV, it appears that certain physiological parameters were better maintained in the DRINK trial, and the trend toward performance differences may be important to elite athletes .
Education regarding the risks of dehydration and overhydration on health and physical performance ids advised.
Wet Bulb Globe Temperature and Heat Injury Prevention
EMA, most sports groups, the Defence Force and many others now use a WBGT.
This WBGT weather measuring device which uses ambient temperature, wind temperature and speed, relative humidity, and solar radiation from the sun; the WBGT in turn generates a number which, when used with the table below indicates risk of heat related illness.
If the WBGT temp increases above 29 (see table below) at a Music dance festival, then the risk of heat related injury increases dramatically and there needs to be an increase in surveillance and cooling mechanisms in the crowd not just at the treatment area.
Portable high efficiency water jet cooling fans, cold packs and advanced resuscitation equipment needs to be carried by advanced first aiders (EMT’s or Medics) mixing in the crowd.
Basic HLTAID003 is not enough as it does not cover advanced resuscitation and airway management, essential for patients suffering from advanced stages of heat illnesses. Also ensuring timely and accurate recording of on the spot HR, BP, SpO2, temperature and other vital signs and patient transport to name a few, whereas PAIEMA (Professional As and accredited EMT’s or Medics and registered Paramedics are qualified to complete these tasks compared to a first aider with HLTAID003.
The Australian Bureau of Meteorology has developed a graph (see below) that can be used to give an approximation of the WBGT measurement for those who don’t have a WBGT available.
About the approximation to the WBGT used by the Bureau of Meteorology
The following information from the Bureau of Meteorology is an approximation and does not take into consideration windspeed and solar radiation, it presumes light winds and moderately radiation levels. Whilst the approximation is useful, it can lead to an incorrect assessment of heat illness risk, therefore a WBGT should be present and monitored at all outdoor events
Prevention is best; don't take illicit drugs, don’t mix alcohol and drugs or take combinations of drugs.
Sports Medicine Australia, Beat the Heat Fact Sheet 
Bureau of Meteorology, Thermal comfort observations 
1. Kiyatkin, E.A., et al., Critical role of peripheral vasoconstriction in fatal brain hyperthermia induced by MDMA (Ecstasy) under conditions that mimic human drug use. Journal of Neuroscience, 2014. 34(23): p. 7754-7762.
2. Camarasa, J., D. Pubill, and E. Escubedo, Association of caffeine to MDMA does not increase antinociception but potentiates adverse effects of this recreational drug. Brain research, 2006. 1111(1): p. 72-82.
3. Frau, L., N. Simola, and M. Morelli, Contribution of caffeine to the psychostimulant, neuroinflammatory and neurotoxic effects of amphetamine-related drugs. Journal of Caffeine Research, 2013. 3(2): p. 79-84.
4. McNamara, R., et al., Caffeine promotes hyperthermia and serotonergic loss following co-administration of the substituted amphetamines, MDMA (“Ecstasy”) and MDA (“Love”). Neuropharmacology, 2006. 50(1): p. 69-80.
5. Vanattou‐Saïfoudine, N., R. McNamara, and A. Harkin, Caffeine provokes adverse interactions with 3, 4‐methylenedioxymethamphetamine (MDMA,‘ecstasy’) and related psychostimulants: mechanisms and mediators. British journal of pharmacology, 2012. 167(5): p. 946-959.
6. Yubero-Lahoz, S., et al., Changes in CYP1A2 activity in humans after 3, 4-methylenedioxymethamphetamine (MDMA, ecstasy) administration using caffeine as a probe drug. Drug metabolism and pharmacokinetics, 2012. 27(6): p. 605-613.
7. Noakes, T.D., Overconsumption of fluids by athletes. British Medical Journal Quality and Safety, 2003.
8. van Dijken, G.D., et al., High incidence of mild hyponatraemia in females using ecstasy at a rave party. Nephrology Dialysis Transplantation, 2013. 28(9): p. 2277-2283.
9. Campbell, G.A. and M.H. Rosner, The agony of ecstasy: MDMA (3, 4-methylenedioxymethamphetamine) and the kidney. Clinical Journal of the American Society of Nephrology, 2008. 3(6): p. 1852-1860.
10. Kalantar-Zadeh, K., et al., Fatal hyponatremia in a young woman after ecstasy ingestion. Nature Reviews Nephrology, 2006. 2(5): p. 283.
11. Speedy, D.B., T.D. Noakes, and C. Schneider, Exercise‐associated hyponatremia: a review. Emergency Medicine, 2001. 13(1): p. 17-27.
12. Mayo Clinic Hyponatraemia. Patient Care & Health Information, 2018.
13. Mann, S.J. and L.M. Gerber, Estimation of 24-h sodium excretion from a spot urine sample using chloride and creatinine dipsticks. American journal of hypertension, 2010. 23(7): p. 743-748.
14. Hew-Butler, T., et al., Exercise-Associated Hyponatremia: 2017 Update. Frontiers in Medicine, 2017. 4(21).
15. Sahay, M. and R. Sahay, Hyponatremia: A practical approach. Indian journal of endocrinology and metabolism, 2014. 18(6): p. 760-771.
16. Owen, B.E., et al., Efficacy of oral versus intravenous hypertonic saline in runners with hyponatremia. Journal of Science and Medicine in Sport, 2014. 17(5): p. 457-462.
17. Rogers, I.R., et al., An intervention study of oral versus intravenous hypertonic saline administration in ultramarathon runners with exercise-associated hyponatremia: a preliminary randomized trial. Clinical Journal of Sport Medicine, 2011. 21(3): p. 200-203.
18. Callaway, C.W. and R.F. Clark, Hyperthermia in Psychostimulant Overdose. Annals of Emergency Medicine, 1994. 24(1): p. 68-76.
19. Sinclair, W.H., et al., Efficacy of field treatments to reduce body core temperature in hyperthermic subjects. Medicine & Science in Sports & Exercise, 2009. 41(11): p. 1984-1990.
20. Gaudio, F.G. and C.K. Grissom, Cooling methods in heat stroke. The Journal of emergency medicine, 2016. 50(4): p. 607-616.
21. Demartini, J.K., et al., Effectiveness of cold water immersion in the treatment of exertional heat stroke at the Falmouth Road Race. Med Sci Sports Exerc, 2015. 47(2): p. 240-245.
22. Zhang, Y., et al., Optimizing Cold Water Immersion for Exercise-Induced Hyperthermia: A Meta-analysis. 2015.
23. Remote Primary Health Care Manuals, CARPA Standard Treatment Manual (7th edition). 2017, Centre for Remote Health: Alice Springs,.
24. Casa, D.J., et al., Intravenous versus oral rehydration during a brief period: responses to subsequent exercise in the heat. Medicine and science in sports and exercise, 2000. 32(1): p. 124-133.
25. Sports Medicine Australia Beat the Heat; Playing and exercising safely in hot weather. 2011.
26. Meteorology, B.o. Thermal comfort observations - Wet Bulb Blobe Temperature (WBGT). 2010 [cited 2019; Available from: http://www.bom.gov.au/info/thermal_stress/#wbgt.
27. Bergeron, M., et al., Youth football: heat stress and injury risk. Medicine & Science in Sports & Exercise, 2005. 37(8): p. 1421-1430.
28. Binkley, H.M., et al., National Athletic Trainers' Association position statement: exertional heat illnesses. Journal of Athletic Training, 2002. 37(3): p. 329.
29. Budd, G.M., Wet-bulb globe temperature (WBGT)—its history and its limitations. Journal of Science and Medicine in Sport, 2008. 11(1): p. 20-32.
30. Casa, D.J., et al., Exertional heat stroke: new concepts regarding cause and care. Current sports medicine reports, 2012. 11(3): p. 115-123.
31. Casa, D.J., et al., National Athletic Trainers' Association position statement: preventing sudden death in sports. Journal of athletic training, 2012. 47(1): p. 96-118.
32. Garigan, T.P. and D.E. Ristedt, Death from hyponatremia as a result of acute water intoxication in an Army basic trainee. Military medicine, 1999. 164(3): p. 234-238.
33. Grundstein, A.J., et al., A retrospective analysis of American football hyperthermia deaths in the United States. International Journal of Biometeorology, 2012. 56(1): p. 11-20.
34. Kerr, Z.Y., et al., Epidemiology of exertional heat illness among US high school athletes. American journal of preventive medicine, 2013. 44(1): p. 8-14.
35. Lee, J.J.Y., et al., Management of hyponatremia. Canadian Medical Association Journal, 2014. 186(8): p. E281-E286.
36. Liamis, G., T.D. Filippatos, and M.S. Elisaf, Treatment of hyponatremia: the role of lixivaptan. Expert review of clinical pharmacology, 2014. 7(4): p. 431-441.
37. M. J van den Heuvel, A., et al., Immersion cooling during hyperthermia: why warmer may be better. 2009.
38. Moritz, M.L. and J.C. Ayus, 100 cc 3% sodium chloride bolus: a novel treatment for hyponatremic encephalopathy. Metabolic brain disease, 2010. 25(1): p. 91-96.
39. Moritz, M.L., K. Kalantar-Zadeh, and J.C. Ayus, Ecstacy-associated hyponatremia: why are women at risk? Nephrology Dialysis Transplantation, 2013. 28(9): p. 2206-2209.
40. Parsons, K., Heat stress standard ISO 7243 and its global application. Industrial health, 2006. 44(3): p. 368-379.
41. Stearns, R., et al., Exertional heat stroke. Preventing sudden death in sport and physical activity, 2012: p. 53-77.
42. Sue, Y.-M., Y.-L. Lee, and J.-J. Huang, Acute Hyponatremia, Seizure, and Rhabdomyolysis After Ecstasy Use. Journal of Toxicology: Clinical Toxicology, 2002. 40(7): p. 931-932.