Sean Nordt and Stuart Swadron
- “Body packers” are defined as patients who ingest packets of pre-packaged drugs, typically in large quantities (sometimes > 100 packets) for the purpose of transport (eg, smuggling).
- This is in contrast to “body stuffers,” who ingest less well packaged drugs in smaller amounts, often spontaneously, when confronted by law enforcement.
- The ingested packets usually consist of condoms, balloons or other latex containers that are double-wrapped, and often covered in wax to minimize leaking and to make them easier to swallow.
- Diagnostic radiology is an integral part of the management of these patients.
- X-ray usually can confirm the diagnosis.
- A CT should be obtained if there is any question about the diagnosis, or if there are any features concerning for bowel obstruction.
- Patients should be placed on continuous cardiac monitoring and IV access obtained.
- Drugs for resuscitation should include ample amounts of sodium bicarbonate for QRS widening (eg, cocaine), naloxone in the event of opioids, and benzodiazepines and other sedatives in the event of a sympathomimetic.
- GI decontamination is the mainstay of treatment
- Activated charcoal 1 g/kg without sorbitol followed by whole bowel irrigation (WBI) with polyethylene glycol-electrolyte solution (PEG-ELS) 1-2L/hour.
- Ideally activated charcoal will bind any leaking drug. It can also be used as a marker of PEG-ELS moving through the GI tract.
- Give antiemetics to prevent nausea and vomiting from PEG-ELS, and consider placing an NG tube to give PEG-ELS.
- Continue until all packets pass and there are several packet-free bowel movements with clear effluent. This may take 24 hours or more.
- When do we call surgery?
- Asymptomatic patients are generally managed non-surgically with GI decontamination.
- If a patient has a small bowel obstruction (SBO) or is symptomatic, particularly with sympathomimetic ingestion, consult surgery.
- Many toxicologists will medically manage symptomatic opioid patients with intermittent naloxone dosing or more commonly a naloxone infusion; although local practice patterns may differ.
- Endoscopy is not generally recommended as it may cause rupture of packets.
- Gastric lavage is not recommended as it is unlikely to cause return of packets and may increase risk of packet rupture, if attempted.
- Patients in custody will typically be observed in a room without a flush toilet so that the packets can be retrieved and medical attention dispatched in the event that the patient becomes more symptomatic or requests treatment.
- If a patient is in custody and refuses treatment or requests to be discharged and has capacity, the treating provider should comply with that request.
EM:RAP 2021 September Body Stuffers
Crunch Time EM: Gastro Drug Packers & Stuffers
tom f. - April 3, 2022 7:01 PM