Two crack cocaine body stuffers

A Case of Cocaine Toxicity From Body Stuffing

Here, we report a case of body stuffing leading to severe cocaine toxicity. Medical management and supportive care are usually the best course of action in cases of body stuffing, as seen in our case. While surgery is rarely indicated, surgical consultation should occur early to ensure prompt intervention if obstruction or perforation occurs.

Complications and hospital stay after endoscopic retrieval of drug baggies in body stuffers: an observational prospective study

Body stuffers routinely receive conservative treatment, i.e. administration of the laxative polyethylene glycol for the passage of ingested drug baggies and observation. Endoscopic baggie removal may offer a safe alternative that could result in shorter hospitalization. We aimed to compare complications, hospital stay, and final outcome in body stuffers assigned to endoscopy versus conservative treatment. This is an observational prospective study of body stuffers presenting to a clinical toxicology center in Tehran (Iran) in 2016-2019, irrespective of the drug ingested. Eligible patients had baggies in their upper gastrointestinal tract and presented without severe poisoning. Patients received either endoscopy or conservative treatment, and clinical outcomes were compared between the groups. A total of 69 patients were enrolled, with a median age of 29 years (range 18-64), among whom 1 was female (2%). Eighteen and 51 patients were endoscopically and conservatively managed, respectively. Drugs most commonly ingested were heroin in endoscopy patients (8/18 cases; 44%) and methamphetamine in the conservative group (28/51 cases; 55%). Endoscopy patients had a shorter hospital stay (median 1.5 vs. 2 days, P = 0.018). In the conservative group, one patient died, and the rate of complications was significantly higher, with more patients experiencing side effects (OR = 1.4, 95% CI = 1.2, 1.7) and requiring intubation (OR = 1.3, 95% CI = 1.1, 1.5). Endoscopic retrieval was associated with fewer complications and shorter hospitalization. Endoscopy may be a safe treatment for body stuffers without severe poisoning on presentation.

Body-Packing: A Rare Diagnosis to Keep in Mind

Body packing was first described in 1973 and refers to the intracorporeal concealment of illegal drugs, which are swallowed or placed in anatomical cavities and/or body orifices. The body packer can be asymptomatic or can have signs of systemic drug toxicity (neurological, cardiac, abdominal, renal and cutaneous) due to rupture of the packet(s) or symptoms of gastrointestinal obstruction or perforation. The diagnosis is established based on a suggestive history, findings on physical examination and laboratory findings and/or imaging. The vast majority of patients are asymptomatic and are treated conservatively. However, complex situations may require surgical intervention. We present a case of a 50-year-old man who was admitted in the emergency department with a generalized tonic-clonic seizure and vomiting with plastic film, which raised the suspicion of foreign body ingestion, confirmed by imaging and laboratory tests. He underwent exploratory laparotomy to remove the packages.

LEARNING POINTS

Body packing is a potentially lethal activity.Body-packers can be asymptomatic, or have signs/symptoms of systemic drug toxicity or gastrointestinal obstruction or perforation.It is essential to recognize this condition so that the correct clinical approach, diagnosis and management can be established.

Polyethylene glycol electrolyte lavage solution increases tablet dissolution of acetaminophen in an in vitro model mimicking acute poisoning

INTRODUCTION

Polyethylene glycol electrolyte lavage solution (PEG-ELS) is similar to pharmaceutical solvent propylene glycol and used following acute poisonings for whole bowel irrigation (e.g., "body stuffing"). This raises concern of PEG-ELS increasing solubility following acute ingestions of non-sustained release xenobiotics in the stomach. We theorized PEG-ELS increases solubility of acetaminophen in an in vitro stomach model.

MATERIAL AND METHODS

An in vitro artificial stomach with 500 mL simulated gastric fluid and either 500 mL of sodium chloride 0.9% (group A) or 500 mL of PEG-ELS (group B). Ten non-sustained release acetaminophen tablets added with concentrations 0, 15, 45 and 90 min in triplicate. Mean concentrations and mean area under the curve (AUC) (mg-min/L to 90 min).

RESULTS

In control group A (normal saline + simulated gastric fluid) mean acetaminophen concentrations 0, 3, 13 and 36 mg/L at 0, 15, 45 and 90 min, respectively. In group B (PEG-ELS + simulated gastric fluid) mean acetaminophen concentrations 0, 34, 109 and 136 mg/L at 0, 15, 45 and 90 min, respectively (p < 0.05). Mean AUC 0-90 1385 [95% C.I. 990.5-1779] mg-min/L in control group A compared to mean AUC 0-90 in group B (PEG-ELS) 7673 mg-min/L [95% C.I. 4832-10513] (p < 0.05).

DISCUSSION

Group B (PEG-ELS) with significantly higher mean acetaminophen concentrations and greater mean AUC compared to control group A (normal saline).

CONCLUSION

We demonstrated increased mean acetaminophen concentrations and increased mean AUC of following exposure of PEG-ELS in an artificial stomach model.

Comparison of low dose and standard dose abdominal CT scan in body stuffers

PURPOSE

Detection of body stuffers is challenging in emergency departments. Because of the small size of baggies, plain radiograph is of little value in most suspects. On the other hand, abdomen CT scan is burdened by high cost and radiation dose. This study was performed to compare the image quality, radiation dose and accuracy of low-dose CT scan in comparison with standard dose.

MATERIAL AND METHODS

In this prospective study, suspected body stuffers who were referred to the radiology department underwent two different protocols of abdominal non-contrast CT scan simultaneously: low-dose (with equivalent dose to conventional abdominal x-ray) and standard dose. Standard dose CT scan was considered as the reference. Low-dose CT scans were evaluated for detection of baggies by two radiologists blinded to the result of standard dose CT. Image quality, noise, dose-length product (DLP) and effective dose (ED) compared between two groups.

RESULTS

The study consisted of 40 patients (33.38 ± 7.4 years). Standard dose CT evaluation was positive in 22 patients (55%). In comparison with standard dose CT scan, low-dose group had a sensitivity of 86%, specificity of 100%, PPV and NPV of 100% and 86%. The accuracy of low-dose CT scan for detection of baggies larger than 1 cm was 100%. However, from the 3 cases that could not be detected with low dose protocol, one had CT features suspected for baggies rupture which was intubated and later deceased. Noise average of low-dose protocol, was approximately 7 times greater than standard dose group, while DLP and ED were 9.7 times less.

CONCLUSION

Low dose CT scan appears to be an appropriate screening method for body stuffers, especially when the baggies are larger than one centimeter. However, in the presence of severe clinical symptoms, a standard dose CT scan will be more helpful due to better image quality especially in suspected ruptured baggies.

The role of radiology in diagnosis and management of drug mules: an update with new challenges and new diagnostic tools

Emergency physicians and radiologists have been increasingly encountering internal concealment of illegal drugs. The packages commonly contain powdered solid drugs such as cocaine, heroin, methamphetamine and hashish, but they may also contain cocaine in the liquid form. The second type of package has recently been more commonly encountered, and poses a greater diagnostic challenge. As clinical evaluation and laboratory tests frequently fail to make the correct diagnosis, imaging examination is typically required. Imaging methods assume a vital role in the diagnosis, follow-up and management. Abdominal X-ray, ultrasonography, CT and MRI are used for the imaging purposes. Among the aforementioned methods, low-dose CT is state-of-the-art in these cases. It is of paramount importance that radiologists have a full knowledge of the imaging characteristics of these packages and accurately guide physicians and security officials.

Imaging of drug smuggling by body packing

Body packing, pushing, and stuffing are hazardous practices with complex medicolegal and social implications. A radiologist plays both a social and a medicolegal role in their assessment, and it should not be limited only to the identification of the packages but must also provide accurate information about their number and their exact location so as to prevent any package remains in the body packer. Radiologists must also be able to recognize the complications associated with these risky practices. Imaging assessment of body packing is performed essentially through plain abdominal X-ray and computed tomography scans. Ultrasound and magnetic resonance imaging, although with some advantages, actually have a limited use.

Validation of a 6-hour observation period for cocaine body stuffers

Often, patients are brought in to the emergency department after ingesting large amounts of cocaine in an attempt to conceal it. This act is known as body stuffing. The observation period required to recognize potential toxic adverse effects in these patients is not well described in the literature. We sought to validate a treatment algorithm for asymptomatic cocaine body stuffers using a 6-hour observation period by observing the clinical course of cocaine body stuffers over a 24-hour period. A retrospective chart review was performed on all patients evaluated for witnessed or suspected stuffing over 2 years using a standardized protocol. One hundred six patients met final inclusion criteria as adult cocaine stuffers. No patients developed life-threatening symptoms, and no patients died during observation. In our medical setting, stuffers could be discharged after a 6-hour observation period if there was either complete resolution or absence of clinical symptoms.

“Parachuting” Meth: A Novel Delivery Method for Methamphetamine and Delayed-Onset Toxicity From “Body Stuffing”

BACKGROUND

Methamphetamine is an illicit stimulant that is typically smoked, insufflated, or injected. We report an unusual method of ingesting methamphetamine called "parachuting" and its implications for the treatment of "body stuffers."

CASE REPORT

A 25-year-old man wrapped methamphetamine into a plastic baggie and ingested it in an attempt to "parachute." He presented to an Emergency Department 10 hours after his ingestion because he realized that he forgot to puncture the baggie. He had no complaints and had a transient tachycardia. He was treated with activated charcoal and whole bowel irrigation, observed for 24 hours, and discharged. He returned 42 hours after his ingestion with tachycardia (220 bpm), agitation, hypertension (179/74 mmHg), and rhabdomyolysis (CPK 7771 U/L), requiring mechanical ventilation and a midazolam drip (10 mg/hr).

CONCLUSION

"Parachuting" is a novel method of ingesting methamphetamine. We report a case of a single-packet "body stuffer" with severe symptom onset that was delayed over 36 hours. Treatment protocols for "body stuffers" using this technique may require more prolonged observation and/or imaging studies to determine the absence of gastrointestinal packets.

Detection of ingested cocaine-filled packets—Diagnostic value of unenhanced CT

PURPOSE

Emergency departments are facing nowadays an increasing number of illegal drug-related health problems, associated with medicolegal and/or social consequences. Body stuffers are street cocaine dealers, who either store wrapped packets of drugs in their rectum or hastily swallow them, prompted by fear of police's arrest. These packets can be life threatening in case of leakage. We evaluate the diagnostic value of unenhanced multidetector CT (MDCT) for detection of cocaine-filled packets (CFP) ingested by body stuffers in a phantom model.

MATERIALS AND METHODS

Our phantom simulated normal bowel contents in which a varying number of true and false CFP were randomly mixed. Both only differ in radiological density. During 18 different reading sessions, four radiologists independently evaluated the presence and number of true and false CFP. Interobserver agreement, sensitivity, specificity, positive and negative predictive value were calculated.

RESULTS

Interobserver agreement for detection of any packets, for visualization of true, and false CFP was good (kappa=0.63, 0.74 and 0.58, respectively). Sensitivity, specificity, positive and negative predictive value for detection of any packets was 95.6%, 100%, 100% and 62.5%, respectively; for visualization of the true CFP 86.5%, 100%, 100% and 77.6%, respectively; and for the false packets 98.1%, 65%, 88.6% and 87.5%, respectively.

CONCLUSION

Unenhanced MDCT without bowel preparation is a fast, reliable and easily reproducible imaging modality for the immediate detection of ingested CFP, thus facilitating medicolegal management of body stuffers.

A five-year review of the medical outcome of heroin body stuffers

The medical outcome of heroin body stuffers has rarely been described. This study was performed to illustrate the clinical course of heroin body stuffers. A retrospective chart analysis was performed on all cases of heroin body stuffers received by a metropolitan poison control center from 2000-2004. We identified 65 heroin body stuffers. Sixty-nine percent were men with a mean age of 35 years. The stated quantity of heroin containers ingested ranged from 1 to 30, with 65% reported as being wrapped in plastic. Six patients (9.2%) developed symptoms of opiate intoxication. All symptoms began within an hour after the ingestion. Three patients (4.6%) needed naloxone. The mean length of observation was 24 h. Opiate intoxication from heroin stuffing is uncommon. Those patients that developed symptoms did so early in their course. These data indicate a benign clinical course in most heroin body stuffers.

The fatal case of a cocaine body-stuffer and a literature review - towards evidence based management

The case of a 50-year old female body-stuffer who collapsed and died more than 10h after swallowing a plastic wrap of cocaine is reported. The case is discussed together with a review of the literature in order that guidelines on managing body-stuffers in police custody can be evidence based.

Street drug abuse leading to critical illness

Critical care physicians are frequently confronted with intoxicated patients who have used street drugs. In the last decade there has been an upward trend in the use of these substances, particularly amongst adolescents and young adults in large urban areas. In excess quantities all street drugs can lead to critical illness. Early and appropriate medical attention by emergency medicine physicians and intensivists can improve outcomes. In this review article we intend to familiarize critical care physicians with the most common street drugs such as amphetamines, ecstasy, cocaine, gamma hydroxybutyrate, opioids, and phencyclidine.

The cocaine "body stuffer" syndrome: a fatal case

Body stuffer, sometimes called "mini packer", is the definition of someone who admits to or is strongly suspected of ingesting illegal drugs in order to escape detection by authorities, and not for recreational purposes or to transport the drug across borders. Cocaine is the drug most commonly involved in the body stuffer syndrome. Reported cases of body stuffer deaths are rare, however a fatality related to the ingestion of a plastic bag containing cocaine is described regarding a 17-year-old dealer. The authors describe how the cocaine body stuffer syndrome differs from the usual body packer. Histological and toxicological findings are examined and discussed for a better definition of this unique syndrome.

Medical outcome of cocaine bodystuffers

To describe the clinical course of cocaine "bodystuffers" presenting to regional emergency departments, a descriptive retrospective analysis was performed on all cases of cocaine bodystuffers received by a metropolitan poison control center and associated toxicology service from January 1993 to May 1994. We identified 46 cases of patients classified as bodystuffers. Of these, 34 patients (74%) remained asymptomatic. Eight patients (18%) had mild symptoms including hypertension and tachycardia that resolved with no treatment beyond decontamination or benzodiazepines (one patient). Two patients (4%) had moderate symptoms including agitation and fever that resolved with no treatment beyond decontamination or benzodiazepines (one patient). Two patients (4%) had severe symptoms including seizure and cardiac dysrhythmia. Both died. Radiographs of the abdomen were negative for foreign body in all 23 examinations performed. Mild cocaine intoxication is common in cocaine bodystuffers. Severe intoxication can occur, resulting in death. Abdominal radiographs are not of value for stuffers ingesting cellophane-wrapped packets. More experience is needed to determine the length of intensive care monitoring that these patients require.

False-negative abdominal CT scan in a cocaine body stuffer

Computed tomography (CT) imaging has been touted as one of the best techniques to detect body packets in body packers and stuffers. The majority of experience has been with body packers. We describe a case of a body stuffer who presented with abdominal pain after ingesting a large packet containing multiple small packets, with a falsely negative abdominal CT scan without contrast. This case raises questions regarding the best method of detection of body packets in body stuffers.

Clinical course of crack cocaine body stuffers

STUDY OBJECTIVE

To describe the clinical course of a cohort of patients presenting to the emergency department with acute crack cocaine body-stuffer syndrome.

METHODS

We conducted a retrospective cohort study in the ED of a county hospital with 75,000 visits per year. Our study cohort comprised all patients who presented between January 1993 and April 1995 and who met the definition of a crack cocaine body stuffer. We defined a crack cocaine body stuffer as anyone who admitted to or was strongly suspected of ingesting crack cocaine as a means of escaping detection by authorities, not for recreational purposes or as a means of transporting the drug across borders.

RESULTS

We identified 98 cases; most such patients were brought to the ED by law enforcement agents. Most were male and younger than 30 years. Self-report by patients indicated that the amount of crack cocaine ingested ranged from 1 to more than 15 rocks. Most commonly the drug was unwrapped (28%) or wrapped in a plastic sandwich bag (29%). Generalized seizures developed in 4% of the patients; in all these patients seizures occurred within 2 hours of ingestion. In no patient did dysrhythmias develop. Many patients had minor signs of cocaine intoxication: 54% were tachycardic, 23% were hypertensive, 22% were agitated, and 19% required sedation.

CONCLUSION

Mild cocaine intoxication is common in crack cocaine body stuffers, with seizures occurring within 2 hours of ingestion in a small percentage of patients.

Foreign bodies in the gastrointestinal tract

Management of foreign bodies of the gastrointestinal tract is not standardized among the various specialties and subspecialties of physicians who care for these patients. This article gives a true emergency department approach to the patient with an ingested or inserted gastrointestinal foreign body. Evaluation and management of the foreign body by location are presented. Controversial issues such as Foley catheter removal of esophageal foreign bodies, management of sharp objects in the stomach, and management of body packers and body stuffers are discussed. Examples of foreign bodies encountered by the typical emergency physician are demonstrated.

Heroin bodypacking

Drug smuggling by internal bodily concealment is a well-recognized international problem, particularly in view of the difficulty of its detection and the potential for large financial gains. This mode of transport can have serious medical complications, including drug intoxication--sometimes fatal--as well as intestinal obstruction by foreign bodies (FBs). We discuss a case of heroin 'bodypacking' (the ingestion of heroin filled condoms) with its resultant complications. The initial medical management and indications for surgery are discussed, and the relevant literature reviewed.

Esophageal Foreign Body after Smoking Crack Cocaine

Injuries from cocaine abuse are often seen and have been reported more often with the introduction of crack cocaine. Burns of the upper aerodigestive tract have been reported but no reports of esophageal obstruction have been located. We report ingestion of a foreign body from smoking crack cocaine and our management. A review of other possible aspiration and ingestion injuries is included.