Body packing: Difference between revisions
 
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==Background==
==Background==
[[File:PMC3522363 iranjradiol-08-205-g002.png|thumb|Abdominal x-ray reveals multiple, oval radiopaque packets throughout the abdomen.]]
[[File:Blausen 0817 SmallIntestine Anatomy.png|thumb|Small bowel anatomy with surrounding structures.]]
* Body packers, also called "mules",  swallow or insert drug filled packets into body cavity, usually to smuggle them across borders
[[File:Bodypacks.jpg|thumb|Seized cocaine containers (i.e. bodypacks).]]
[[File:PMC3522363 iranjradiol-08-205-g001.png|thumb|Illicit drugs evacuated from a body packer. They are packed tightly and wrapped into aluminum foil.]]
*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
*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<ref>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.</ref>
*Each packet contains about 10g of drug and body packers ingest between 50 to 100 drug containers at a time<ref>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.</ref>
*Sometimes packets are inserted rectally or vaginally
*Sometimes packets are inserted rectally or vaginally
* Versus body stuffing, ingestion of illicit drugs while pursued by law enforcement; usually small quantity
*Distinct from [[Body stuffing]] (ingestion of illicit drugs while pursued by law enforcement, usually small quantity)
 
{{FB types}}


==Clinical Features==
==Clinical Features==
*Situations in which body packers present to the ED:
*Situations in which body packers present to the ED:
**Asymptomatic but in custody  
**Asymptomatic but in custody  
**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
**Type of drug
**Type of packet wrapping (more likely to rupture or leak if home made)
**Number of packets ingested
**GI symptoms ([[abdominal pain|pain]], distention, obstipation)
**Other drug use


==Differential Diagnosis==
==Differential Diagnosis==
{{Drugs of abuse types}}


==Evaluation==
==Evaluation==
* History and physical
[[File:PMC3522363 iranjradiol-08-205-g002.png|thumb|Abdominal x-ray reveals multiple, oval radiopaque packets throughout the abdomen.]]
**Type of drug
[[File:Bolletjes.jpg|thumb|Abdominal X-ray showing swallowed packages of cocaine.]]
**Type of packet wrapping (more likely to rupture or leak if home made)
[[File:PMC3522363 iranjradiol-08-205-g005.png|thumb|(A) plain x-ray reveals several uniform radiopaque packets; B-C, Abdominal CT scan without oral contrast shows numerous randomly distributed packets within the small bowel and colon. Their density is 150-170HU which is compatible with the density of opium.]]
**Number of packets ingested
**GI symptoms (pain, distention, obstipation)
**Other drug use
*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
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**History is unreliable
**History is unreliable
**Passage of 2 or 3 packet free bowel movements is not sufficient<ref>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.</ref>
**Passage of 2 or 3 packet free bowel movements is not sufficient<ref>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.</ref>
==See Also==
==See Also==
*[[Body stuffing]]
*[[Drugs of abuse]]
*[[Ingested foreign body]]
*[[Ingested foreign body]]
*[[Rectal foreign body]]
*[[Rectal foreign body]]
==External Links==
==External Links==


==References==
==References==
<references/>
<references/>
[[Category:GI]]
[[Category:Toxicology]]

Latest revision as of 22:48, 28 February 2024

Background

Small bowel anatomy with surrounding structures.
Seized cocaine containers (i.e. bodypacks).
Illicit drugs evacuated from a body packer. They are packed tightly and wrapped into aluminum foil.
  • 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)

Foreign Body Types

Clinical Features

  • Situations in which body packers present to the ED:
  • 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

Drugs of abuse

Evaluation

Abdominal x-ray reveals multiple, oval radiopaque packets throughout the abdomen.
Abdominal X-ray showing swallowed packages of cocaine.
(A) plain x-ray reveals several uniform radiopaque packets; B-C, Abdominal CT scan without oral contrast shows numerous randomly distributed packets within the small bowel and colon. Their density is 150-170HU which is compatible with the density of opium.

Management

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

  1. ↑ 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.
  2. ↑ 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.
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