30 y/o male pt who presents to Englewood 30 y/o male pt who presents to Englewood Hospital ER after being found in bed at a Hospital ER after being found in bed at a rooming house, unresponsive by Landlord. rooming house, unresponsive by Landlord. Noticed to have laxative bottles in floor.Noticed to have laxative bottles in floor.

As per EMS, pt with poor/shallow As per EMS, pt with poor/shallow respirations, pinpoint pupils Non Rxrespirations, pinpoint pupils Non Rx

VS: HR 150 RR 8 BP 136/60 Pulse Ox 86% VS: HR 150 RR 8 BP 136/60 Pulse Ox 86% on NRBM, BS= 127on NRBM, BS= 127

Given IVF NS, Thiamine 100mg, Narcan Given IVF NS, Thiamine 100mg, Narcan 2mg IV2mg IV

In the ER, pt VS: HR 150 RR 12 BP 106/77 In the ER, pt VS: HR 150 RR 12 BP 106/77 Temp 103.6 O2 Sat 90 on NRBMTemp 103.6 O2 Sat 90 on NRBM

Pt received Narcan 2mg IV w/o responsePt received Narcan 2mg IV w/o response

Pt intubated for airway protectionPt intubated for airway protection

CXR / ABD xray done……pt sent for a CXR / ABD xray done……pt sent for a Head CT and ABD/Pelvic CTHead CT and ABD/Pelvic CT

LABSLABS

ETOH, Acetaminophen, Salicylate , THC , ETOH, Acetaminophen, Salicylate , THC , Cocaine, Amphetamines, Barb., Cocaine, Amphetamines, Barb., Benzodiazepim ( Neg )Benzodiazepim ( Neg )

Opiate Opiate ( Positive ) ( Positive )

Pt sent to the ORPt sent to the OR

??

HEROINENOMAHEROINENOMA

BodyBody PackingPacking

The Internal Concealment of The Internal Concealment of Illicit DrugsIllicit Drugs

• Body packing is a distinct method of drug Body packing is a distinct method of drug smuggling.smuggling.

• Surgeons and intensive care specialists will be Surgeons and intensive care specialists will be confronted with body packers when packets do confronted with body packers when packets do not pass spontaneously and rupture, causing not pass spontaneously and rupture, causing drug toxicitydrug toxicity

• This mode of transport can have serious This mode of transport can have serious medical complications, including drug medical complications, including drug intoxication--sometimes fatal--as well as intoxication--sometimes fatal--as well as intestinal obstruction by foreign bodies (FBs). intestinal obstruction by foreign bodies (FBs).

In addition to transporting cocaineIn addition to transporting cocaine and and heroin, body packers may smuggle heroin, body packers may smuggle marijuana, hashish, amphetamines, or marijuana, hashish, amphetamines, or methylenedioxymethamphetaminemethylenedioxymethamphetamine

("ecstasy"),.("ecstasy"),. Body packers usually carryBody packers usually carry about 1 kg (2.2 about 1 kg (2.2

lb) of drug, divided into 50 to 100 packetslb) of drug, divided into 50 to 100 packets

of 8 to 10 g each (0.3 to 0.4 oz)of 8 to 10 g each (0.3 to 0.4 oz) the drug is denselythe drug is densely packed into a latex packed into a latex

sheath, such as a condom or balloon. Thissheath, such as a condom or balloon. This

layer is tied at the open end, covered with layer is tied at the open end, covered with several other layersseveral other layers of latex, and sealed with of latex, and sealed with a hard wax coatinga hard wax coating

Unless the patient is being prepared for Unless the patient is being prepared for immediate surgery,immediate surgery, gastrointestinal gastrointestinal decontamination should be attempted with decontamination should be attempted with ActivatedActivated charcoal, lg percharcoal, lg per kilogram of body kilogram of body weight (up to 50 g) weight (up to 50 g)

Whole-bowel irrigation with a polyethylene Whole-bowel irrigation with a polyethylene glycol–electrolyteglycol–electrolyte lavage solution lavage solution

The use of oil-basedThe use of oil-based laxatives shouldlaxatives should be be avoided because they reduce the tensile avoided because they reduce the tensile strength and "burst"strength and "burst" volume of latex volume of latex productsproducts

high doses of high doses of naloxonenaloxone may be may be required to reverse toxicity in body required to reverse toxicity in body packers. packers.

An appropriate initial dose is 2-5 An appropriate initial dose is 2-5 mg IV, with repeat doses of 2 mg mg IV, with repeat doses of 2 mg given every 5 minutes until the given every 5 minutes until the patient is responsivepatient is responsive

The total amount given to achieve The total amount given to achieve a response should then be given a response should then be given every hour as a continuous every hour as a continuous infusion until all packets have infusion until all packets have passed.passed.

Successful endoscopic removal of packets Successful endoscopic removal of packets from the stomachfrom the stomach has been reported, the risk has been reported, the risk of packet rupture during the procedureof packet rupture during the procedure has has led others to caution against itled others to caution against it

Packets that are accessiblePackets that are accessible to the to the endoscopist most likely represent only a endoscopist most likely represent only a fraction offraction of the gastrointestinal burden, and the gastrointestinal burden, and the risk of rupture the risk of rupture in removing the packets in removing the packets usually outweighs the benefit.usually outweighs the benefit.

CT and barium-enhanced CT and barium-enhanced radiography are both more radiography are both more sensitive than plain abdominal sensitive than plain abdominal radiographs radiographs

hashish is denser than stool; hashish is denser than stool; cocaine appears similar to stool; cocaine appears similar to stool; and heroin has a gaseous and heroin has a gaseous transparence.transparence.

                                                       

Consultation with a medical Consultation with a medical toxicologist or a regional poison-toxicologist or a regional poison-

control center is also advisedcontrol center is also advised

Eur Radiol. 2005 Jan;15(1):193Eur Radiol. 2005 Jan;15(1):193

value of abdominal ultrasound for the detection of value of abdominal ultrasound for the detection of intestinal drug containers in air travelers suspected of intestinal drug containers in air travelers suspected of intestinal drug trafficking.intestinal drug trafficking.

• 50 suspects charged with intestinal drug smuggling50 suspects charged with intestinal drug smuggling• portable ultrasound unit (SonoSite 180) was used with a 2- to portable ultrasound unit (SonoSite 180) was used with a 2- to

4-MHz curved-array transducer4-MHz curved-array transducer• 40 of 42 suspects abdominal ultrasound correctly identified the 40 of 42 suspects abdominal ultrasound correctly identified the

presence of containerspresence of containers• positive predictive value of an ultrasound examination was positive predictive value of an ultrasound examination was

97.6%97.6%