ICEM 2014

ICEM 2014

Tintinalli Headlines & Holliman Assumes Presidency

On June 11, EPM Editor-in- Chief and renowned educator Judith Tintinalli took to the stage in Hong Kong to address…

The Medical Malpractice Rundown: A State-by-State Report Card

The Medical Malpractice Rundown: A State-by-State Report Card

When it comes to medical liability laws and culture, where you live matters.

Find out how your state stacks up against the other 49.

CT – Lowering Cost and Radiation

CT – Lowering Cost and Radiation

Medicare pays only about 20% of typical charges and radiation can be reduced by 90%.

The cost of a CT is actually quite nominal – the charge, however, is an entirely different matter. 

 Aftermath: The Night Shift Season 1 Finale Review

Aftermath: The Night Shift Season 1 Finale Review

At Loose Ends

It’s strange calling this a season finale, because it’s only been an 8-episode summer run, and nearly every episode has…

Doximity’s Next Trick: Connectivity at the Point of Care

Doximity’s Next Trick: Connectivity at the Point of Care

You’ve raised $81 million in investments and your physician membership now exceeds that of the AMA. What’s next?

If you're Doximity, it's time to dream big. 

Subcutaneous Insulin in DKA: Safe — But Not Better

Subcutaneous Insulin in DKA: Safe — But Not Better

Newer Isn't Always Better

Studies show that the benefits of subcutaneous insulin over old fashioned IV insulin are marginal at best.

A Return to (Lousy) Form: Episode 7 of The Night Shift

A Return to (Lousy) Form: Episode 7 of The Night Shift

Forks! Strippers! Guns!

Once again, our characters are responding to the (frankly unbelievable) events unfolding around them, rather than driving the action.

Oxygen is a Drug— Act Accordingly

Oxygen is a Drug— Act Accordingly

Understanding the dangers of indiscriminate oxygenation in the ED setting

As with many things in medicine, dogma seems to overpower the evidence in this arena. 

Oh Henry: A Sucker is Born Every Minute

Oh Henry: A Sucker is Born Every Minute

Pharmaceutical Ads, Government, and the Physician-Patient Relationship

Though it pains me to say it, this is one time where caveat emptor doesn’t apply. 


A Ray of Hope

A Ray of Hope

The Night Shift, episode 6

This was the first episode where it felt like the characters were driving the plot.

The Downside of the Upswing

The Downside of the Upswing

You should have cashed in big-time. 
But did you?

The last several years of returns have been among the best ever.

5 Things Your Patients Might Think After Watching ‘Code Black’

5 Things Your Patients Might Think After Watching ‘Code Black’

An inside view of the ED

Code Black provides a harrowing and enlightening window into the front lines of healthcare. 

Talking Points

Talking Points

Link your vision to action

As an ED leader, you must not only have a vision and plan, but you must communicate that vision effectively…

Toxic Liquid Nicotine

Toxic Liquid Nicotine

New FDA regulations proposed for E-cigs

Highly unregulated, the sale of toxic nicotine concoctions for e-cigarette refills pose a serious threat to children.

All Choked Up

All Choked Up

Best Practices for Battery Ingestion

A two-year-old presents at a clinic with persistent cough and neck discomfort and winds up in the ED.

Gag Order

Gag Order

New ruling prohibits would-be ACEP leaders from answering questions from non-ACEP publications.

Greg Henry seldom fails to deliver on a promise. But this time, it looks like it’s out of his control.

Lock the Gates!

Lock the Gates!

Board certification is vital in EM

Last month, Rick Bukata suggested that ACEP open its gates to non-boarded EPs. 
This would be an insult to EM…

AMA Meeting Highlights

AMA Meeting Highlights

Association Gives Nod to First EP President-elect

This June’s AMA Annual Meeting proved as eventful as ever, with one exciting twist that has the potential to impact…

The Storm Episode!

The Storm Episode!

Episode 5 of NBC's "The Night Shift"

It’s time for the passion that’s been building up between the two lead ED doctors for … the past few…

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Educational Objectives:
After evaluating this article participants will be able to:
-Identify issues associated with body packers and stuffers
-Implement different treatment strategies for body packers and stuffers
-Recognize the critical differences between body packers and stuffers

 
The patient is a 30-year-old male who presents to an inner city ED after “swallowing several dime bags of cocaine” approximately 1 hour ago while being pursued by the police. He complains of chest pain and headache but is refusing any medical intervention and wants to sign out AMA. He is agitated, diaphoretic, and verbally abusive to the ED staff. His vital signs document a pulse of 120 beats per minute; respiratory rate of 32 breaths per minute; blood pressure of 180/110mmHg and an oral temperature of 102 F.

*****************
 
With international drug trafficking on the rise, it is important for emergency physicians to be aware of methods of drug concealment. “Body stuffers” is the term used to describe individuals who rapidly swallow illegal contraband such as cocaine or heroin in an attempt to avoid prosecution when confronted by the police or authorities. “Body packers” swallow or pack a selected body orifice with drugs in an attempt to conceal and illegally transport paraphernalia across international borders. Body packing uses more methodical means of packaging such as multilayered latex, rubber or condoms to prevent the packets from rupturing in transit (figure 1).
 
alt 
 
The average number of packets ingested may vary, but can be well over 100. Massive overdose will occur in individuals if any of these packets rupture, releasing a potentially lethal dose of drug. Body packers often ingest constipating agents such as diphenoxylate/atropine (Lomotil) to hold back the intestinal contents during long flights or transport. In contrast, body stuffers generally have poorly wrapped drugs, which are likely to be systemically absorbed, although in much less concentrated amounts than the body packer scenario. Packaging methods likely to leak include paper, aluminum foil, duct tape (yet another use), and loosely secured plastic bags.

alt


altThe physician should attempt to obtain any information regarding the amount of drug ingested and the type of packaging to predict the potential for toxicity. Plain abdominal radiographs are generally not useful for body stuffers, but may be positive with body packers (figure 3). Gastrograffin swallow or CT scan of the abdomen with contrast may reveal ingested packets in cases where plain radiographs are negative, but tend to be nonspecific and reader dependant. ED bedside ultrasonography would be a noninvasive method to rapidly assess for multiple drug packets, particularly in the gastric region.

 
 
 
In overdose, cocaine toxicity will cause a sympathomimetic toxidrome manifested by agitation, mydriasis, diaphoresis, hypertension, tachycardia, and hyperthermia.
 
Benzodiazepines are the first line agents for reversing mild to moderate cocaine-induced sympathetic symptoms. Active cooling measures are critical in victims with profound hyperthermia. Cardiotoxicity manifesting as acute coronary syndromes and myocardial infarctions, as well as cerebral vascular accidents and intracranial bleeds have been well documented in patients with cocaine toxicity. 

In body stuffers and packers, gastric lavage is ineffective and contraindicated, as the procedure may cause rupture of the packets. Conservative therapy using polyethylene glycol whole bowel irrigation (WBI) is generally recommended in patients with potential toxicity. The most common product, trade named “GoLytely”, (I challenge anyone to come up with a better medical misnomer) is dosed at 1-2 liters per hour. It often requires NG tube administration unless the patient is cooperative. In patients who are extremely agitated, combative or exhibit violent behavior, WBI should be withheld. Activated charcoal is given prior to whole bowel irrigation to adsorb any leaking drug from the packets. Charcoal noted in the rectal effluent also helps indicate a completed round of WBI. It is important to ensure that all ingested packets are accounted for before the patient is discharged. After cleaning off the charcoal residue, turn any illegal contraband over to hospital security or the proper authorities—for obvious reasons, avoid “pocketing the evidence”. Patients in police custody are particularly high risk for subsequent morbidity due to a lack of reliable follow-up care or means of close observation and monitoring. Body packers with significant toxicity or evidence of bowel obstruction should have a surgical consultation. Laparotomy may be a necessary lifesaving intervention to remove leaking packets.

Body packers or stuffers with heroin or opioid-containing drugs may present with altered mental status, depressed respiratory drive, and miotic pupils. These patients may also require GI decontamination with whole bowel irrigation in order to enhance the elimination of drug packets. Contraindications to WBI include unstable vital signs, respiratory compromise, and lack of bowel sounds or gut motility. In contrast to scenarios involving cocaine, a less aggressive approach to surgical intervention is warranted with heroin packing. Supportive care and antidotal therapy with naloxone may be required for more prolonged periods of time. A recent five year case series from Chicago reported a relatively benign clinical course in most heroin body stuffers. Nine percent of patients developed signs and symptoms consistent with opiate intoxication and only 5% required naloxone administration. The mean observation time in this series was 24 hours.

Other drugs of abuse described in isolated cases of body packers and stuffers include methamphetamines, phencyclidine, cannabinoids and various hallucinogens.

 
Trivia question #2: Why did 249 Boa Constrictors die from a cocaine overdose in June, 1993? 
Answer: They were being used as “body packers” to smuggle cocaine into the US from South America.


References

  • Dattilo P, Hailpern S, Fearon K, et al: B-blockers are associated with reduced risk of myocardial infarction after cocaine use. Ann Emerg Med 51(2): 117-126, 2008.
  • Eng JG, Aks SE, Waldron R, et al: False-negative abdominal CT scan in a cocaine body stuffer. Am J Emerg Med 17:702-4,1999.
  • Goertemoeller S, Behrman A: The risky business of body packers and body stuffers  J of Emerg Nursing, Volume 32 (6), 541-544, 2006.
  • Hoffman RS: Cocaine and B-blockers: should the controversy continue? Annal Emerg Med 51(2): 127-129, 2008.
  • Hoffman RS, Smilkstein MJ, Goldfrank LR: Whole bowel irrigation and the cocaine body packer: a new approach to a common problem. Am J Emerg Med 8(6):523-527, 1990.
  • Jordan MT, et al: A recent case series reported nine percent (6/65) of patients developed signs and symptoms consistent with opiate intoxication after oral stuffing of heroin. J Emerg Med. 36(3): 250-256, 2009.
  • June R, et al: Medical outcome of cocaine body stuffers. J Emerg Med  1(2):221-224, 2000.
  • Olmedo R, et al: Is surgical decontamination definitive treatment of “body packers”? Am J Emerg Med  19(7):593-96, 2001.
  • Roberts JR, et al: The body stuffer syndrome: a clandesteine form of drug overdose. Am J Emerg Med  4(1):24-27, 1986.
  • Schaper A, et al: Surgical treatment of cocaine packers and body pushers. Int J Colorectal Dis 22(12): 1531-35, 2007.
  • Taheri MS, Moharamzad Y, Nahvi V: Abdominal CT findings of ruptured opium packets in a body packer European Journal of Radiology Extra, Volume 70 (1): e21-e23, 2009. 
  • Traub SJ, Hoffman RS, Nelson LS: Body packing-The internal concealment of illicit drugs. N Engl J Med 349; 26: 2519-26, 2003.
  • Utecht MJ, Stone AF, McCarron MM: Heroin body packers. J Emerg Med 159:750-754, 1993.
     

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