1. 30 y/o male pt who presents to Englewood Hospital ER after being found in bed at a rooming house, unresponsive by Landlord. Noticed to have laxative bottles in floor. 30 y/o male pt who presents to Englewood Hospital ER after being found in bed at a rooming house, unresponsive by Landlord. Noticed to have laxative bottles in floor. As per EMS, pt with poor/shallow respirations, pinpoint pupils Non Rx As per EMS, pt with poor/shallow respirations, pinpoint pupils Non Rx VS: HR 150 RR 8 BP 136/60 Pulse Ox 86% on NRBM, BS= 127 VS: HR 150 RR 8 BP 136/60 Pulse Ox 86% on NRBM, BS= 127 Given IVF NS, Thiamine 100mg, Narcan 2mg IV Given IVF NS, Thiamine 100mg, Narcan 2mg IV

2. In the ER, pt VS: HR 150 RR 12 BP 106/77 Temp 103.6 O2 Sat 90 on NRBM In the ER, pt VS: HR 150 RR 12 BP 106/77 Temp 103.6 O2 Sat 90 on NRBM Pt received Narcan 2mg IV w/o response Pt received Narcan 2mg IV w/o response Pt intubated for airway protection Pt intubated for airway protection CXR / ABD xray done……pt sent for a Head CT and ABD/Pelvic CT CXR / ABD xray done……pt sent for a Head CT and ABD/Pelvic CT

6. LABS ETOH, Acetaminophen, Salicylate, THC, Cocaine, Amphetamines, Barb., Benzodiazepim ( Neg ) ETOH, Acetaminophen, Salicylate, THC, Cocaine, Amphetamines, Barb., Benzodiazepim ( Neg ) Opiate ( Positive ) Opiate ( Positive ) Pt sent to the OR Pt sent to the OR

12. ? HEROINENOMA

17. Body Packing The Internal Concealment of Illicit Drugs

18. Body packing is a distinct method of drug smuggling. Body packing is a distinct method of drug smuggling. Surgeons and intensive care specialists will be confronted with body packers when packets do not pass spontaneously and rupture, causing drug toxicity Surgeons and intensive care specialists will be confronted with body packers when packets do not pass spontaneously and rupture, causing drug toxicity This mode of transport can have serious medical complications, including drug intoxication--sometimes fatal--as well as intestinal obstruction by foreign bodies (FBs). This mode of transport can have serious medical complications, including drug intoxication--sometimes fatal--as well as intestinal obstruction by foreign bodies (FBs).

19. In addition to transporting cocaine and heroin, body packers may smuggle marijuana, hashish, amphetamines, or methylenedioxymethamphetamine ("ecstasy"),. In addition to transporting cocaine and heroin, body packers may smuggle marijuana, hashish, amphetamines, or methylenedioxymethamphetamine ("ecstasy"),. Body packers usually carry about 1 kg (2.2 lb) of drug, divided into 50 to 100 packets of 8 to 10 g each (0.3 to 0.4 oz) Body packers usually carry about 1 kg (2.2 lb) of drug, divided into 50 to 100 packets of 8 to 10 g each (0.3 to 0.4 oz) the drug is densely packed into a latex sheath, such as a condom or balloon. This layer is tied at the open end, covered with several other layers of latex, and sealed with a hard wax coating the drug is densely packed into a latex sheath, such as a condom or balloon. This layer is tied at the open end, covered with several other layers of latex, and sealed with a hard wax coating

21. Unless the patient is being prepared for immediate surgery, gastrointestinal decontamination should be attempted with Activated charcoal, lg per kilogram of body weight (up to 50 g) Unless the patient is being prepared for immediate surgery, gastrointestinal decontamination should be attempted with Activated charcoal, lg per kilogram of body weight (up to 50 g) Whole-bowel irrigation with a polyethylene glycol–electrolyte lavage solution Whole-bowel irrigation with a polyethylene glycol–electrolyte lavage solution The use of oil-based laxatives should be avoided because they reduce the tensile strength and "burst" volume of latex products The use of oil-based laxatives should be avoided because they reduce the tensile strength and "burst" volume of latex products

22. high doses of naloxone may be required to reverse toxicity in body packers. high doses of naloxone may be required to reverse toxicity in body packers. An appropriate initial dose is 2-5 mg IV, with repeat doses of 2 mg given every 5 minutes until the patient is responsive An appropriate initial dose is 2-5 mg IV, with repeat doses of 2 mg given every 5 minutes until the patient is responsive The total amount given to achieve a response should then be given every hour as a continuous infusion until all packets have passed. The total amount given to achieve a response should then be given every hour as a continuous infusion until all packets have passed.

23. Successful endoscopic removal of packets from the stomach has been reported, the risk of packet rupture during the procedure has led others to caution against it Successful endoscopic removal of packets from the stomach has been reported, the risk of packet rupture during the procedure has led others to caution against it Packets that are accessible to the endoscopist most likely represent only a fraction of the gastrointestinal burden, and the risk of rupture in removing the packets usually outweighs the benefit. Packets that are accessible to the endoscopist most likely represent only a fraction of the gastrointestinal burden, and the risk of rupture in removing the packets usually outweighs the benefit.

24. CT and barium-enhanced radiography are both more sensitive than plain abdominal radiographs CT and barium-enhanced radiography are both more sensitive than plain abdominal radiographs hashish is denser than stool; cocaine appears similar to stool; and heroin has a gaseous transparence. hashish is denser than stool; cocaine appears similar to stool; and heroin has a gaseous transparence.

26. Consultation with a medical toxicologist or a regional poison- control center is also advised

27. Eur Radiol. 2005 Jan;15(1):193 value of abdominal ultrasound for the detection of intestinal drug containers in air travelers suspected of intestinal drug trafficking. value of abdominal ultrasound for the detection of intestinal drug containers in air travelers suspected of intestinal drug trafficking. 50 suspects charged with intestinal drug smuggling 50 suspects charged with intestinal drug smuggling portable ultrasound unit (SonoSite 180) was used with a 2- to 4-MHz curved-array transducer portable ultrasound unit (SonoSite 180) was used with a 2- to 4-MHz curved-array transducer 40 of 42 suspects abdominal ultrasound correctly identified the presence of containers 40 of 42 suspects abdominal ultrasound correctly identified the presence of containers positive predictive value of an ultrasound examination was 97.6% positive predictive value of an ultrasound examination was 97.6%