Body Packers

Body Packers

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.
• Management
  • 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.

Pitfalls

• • 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.
• Disposition
  • 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.

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