Body packing: Difference between revisions
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**Signs of [[toxidromes]] from a ruptured packet | **Signs of [[toxidromes]] from a ruptured packet | ||
**Signs of [[bowel obstruction]] or perforation | **Signs of [[bowel obstruction]] or perforation | ||
*History and physical | *History and physical | ||
**Type of drug | **Type of drug | ||
**Type of packet wrapping (more likely to rupture or leak if home made) | **Type of packet wrapping (more likely to rupture or leak if home made) | ||
**Number of packets ingested | **Number of packets ingested | ||
**GI symptoms (pain, distention, obstipation) | **GI symptoms ([[abdominal pain|pain]], distention, obstipation) | ||
**Other drug use | **Other drug use | ||
==Differential Diagnosis== | |||
==Evaluation== | |||
*Imaging: KUB, CT abdomen pelvis | *Imaging: KUB, CT abdomen pelvis | ||
*[[Urine drug screen]]: may be misleading | *[[Urine drug screen]]: may be misleading | ||
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**Expectant management, no surgery, close monitoring in ICU until passage of all packets | **Expectant management, no surgery, close monitoring in ICU until passage of all packets | ||
**[[Whole bowel irrigation]] with polyethylene glycol via NGT at 2L per hour | **[[Whole bowel irrigation]] with polyethylene glycol via NGT at 2L per hour | ||
**Activated charcoal more useful in body stuffers | **[[Activated charcoal]] more useful in body stuffers | ||
*[[Opioid toxicity]] | *[[Opioid toxicity]] | ||
**Naloxone: may require very high doses | **[[Naloxone]]: may require very high doses | ||
***2 to 5mg IV initially, repeat 2mg q5min until responsive | ***2 to 5mg IV initially, repeat 2mg q5min until responsive | ||
***then total amount required for response should be given every hour as continuous drip | ***then total amount required for response should be given every hour as continuous drip | ||
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**No place for conservative management | **No place for conservative management | ||
**Pharmacologic stabilization appropriate but not definitive, do not delay transfer to the OR | **Pharmacologic stabilization appropriate but not definitive, do not delay transfer to the OR | ||
***Hyperthermia | ***[[Hyperthermia]] | ||
****Active external cooling | ****Active external cooling | ||
****IV [[benzodiazepines]] ([[midazolam]] 1 to 2mg IV or [[diazepam]] 5 to 10 mg IV, rapid escalation in dosing) | ****IV [[benzodiazepines]] ([[midazolam]] 1 to 2mg IV or [[diazepam]] 5 to 10 mg IV, rapid escalation in dosing) | ||
***Hypertension | ***[[Hypertension]] | ||
****IV benzodiazepines, [[phentolamine]], [[nitroprusside]], [[nitroglycerin]],, or [[nicardipine]] | ****IV [[benzodiazepines]], [[phentolamine]], [[nitroprusside]], [[nitroglycerin]],, or [[nicardipine]] | ||
***Seizures | ***[[Seizures]] | ||
****IV benzodiazepines, followed by [[propofol]] if needed | ****IV [[benzodiazepines]], followed by [[propofol]] if needed | ||
***Ventricular dysrhythmias | ***[[Ventricular dysrhythmias]] | ||
****IV benzodiazepines, followed by hypertonic sodium bicarbonate if wide QRS | ****IV [[benzodiazepines]], followed by hypertonic [[sodium bicarbonate]] if wide QRS | ||
*Obstruction or perforation | *[[bowel obstruction|Obstruction]] or perforation | ||
**OR for immediate ex-lap, then advanced imaging study to document a clear GI tract | **OR for immediate ex-lap, then advanced imaging study to document a clear GI tract | ||
**Endoscopic removal highly controversial, risk of packet perforation | **Endoscopic removal highly controversial, risk of packet perforation | ||
Revision as of 19:43, 29 September 2019
Background
- Body packers, also called "mules", swallow or insert drug filled packets into body cavity, usually to smuggle them across borders
- Packets usually made of several layers of latex and outer wax coating
- Each packet contains about 10g of drug and body packers ingest between 50 to 100 drug containers at a time[1]
- Sometimes packets are inserted rectally or vaginally
- Distinct from Body stuffing (ingestion of illicit drugs while pursued by law enforcement, usually small quantity)
Clinical Features
- Situations in which body packers present to the ED:
- Asymptomatic but in custody
- Signs of toxidromes from a ruptured packet
- Signs of bowel obstruction or perforation
- History and physical
- Type of drug
- Type of packet wrapping (more likely to rupture or leak if home made)
- Number of packets ingested
- GI symptoms (pain, distention, obstipation)
- Other drug use
Differential Diagnosis
Evaluation
- Imaging: KUB, CT abdomen pelvis
- Urine drug screen: may be misleading
Management
- Asymptomatic patients
- Expectant management, no surgery, close monitoring in ICU until passage of all packets
- Whole bowel irrigation with polyethylene glycol via NGT at 2L per hour
- Activated charcoal more useful in body stuffers
- Opioid toxicity
- Naloxone: may require very high doses
- 2 to 5mg IV initially, repeat 2mg q5min until responsive
- then total amount required for response should be given every hour as continuous drip
- Naloxone: may require very high doses
- Sympathomimetic toxicity
- Immediate OR for surgical decontamination
- No place for conservative management
- Pharmacologic stabilization appropriate but not definitive, do not delay transfer to the OR
- Hyperthermia
- Active external cooling
- IV benzodiazepines (midazolam 1 to 2mg IV or diazepam 5 to 10 mg IV, rapid escalation in dosing)
- Hypertension
- Seizures
- IV benzodiazepines, followed by propofol if needed
- Ventricular dysrhythmias
- IV benzodiazepines, followed by hypertonic sodium bicarbonate if wide QRS
- Hyperthermia
- Obstruction or perforation
- OR for immediate ex-lap, then advanced imaging study to document a clear GI tract
- Endoscopic removal highly controversial, risk of packet perforation
Disposition
- Admit all to ICU, regardless of symptoms
- Complete GI decontamination by contrast CT should be documented prior to discharge
- History is unreliable
- Passage of 2 or 3 packet free bowel movements is not sufficient[2]
See Also
External Links
References
- ↑ Booker RJ. Packers, pushers and stuffers--managing patients with concealed drugs in UK emergency departments: a clinical and medicolegal review. Emerg Med J. 2009;26(5):316-20.
- ↑ Rousset P. Detection of residual packets in cocaine body packers: low accuracy of abdominal radiography-a prospective study. Eur Radiol. 2013;23(8):2146-55.