sign in sign up
<<
Home , Toxidrome

20 Case Reports

Foreign material in the : medical care and review of toxidromes

Authors: Author Affiliations: Ada Gu¹, Tim O’Shea¹, Ameen Patel¹ 1. Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON

Author for Correspondence: Ada Gu [email protected] ABSTRACT:

Body packing as a method of international drug transport is a potentially lethal crime that has been continually reported and studied since the first published report more than 30 years ago.¹ The typical cause of death in individuals transporting drugs, also known as ‘body packers,’ is acute drug resulting from ruptured packets. There is no definitive protocol for management of these patients; the type of concealed drug, the patient condition and the capabilities of the treatment center dictate treatment. Although surgical intervention has become more frequent due to increasingly sophisticated packaging techniques, conservative management is generally preferred; the current treatment of choice is polyethylene glycol (PEG). Early surgical management however results in fewer emergent complications such as gastrointestinal obstruction, perforation, toxicity or retention. There is a lack of guidance regarding the reporting protocol and the healthcare team faces difficulty in balancing the rights of the individual with societal and criminal reporting responsibilities. We report a case of toxicity from ingested packets of cocaine with a brief review of physician reporting considerations, and a focus on medical management and review of common toxidromes.

Key words: Body packers, Cocaine toxicity, Gastrointestinal Tract, Treatment, Surgery, Reporting Protocol, Ethics.

CASE REPORT 3. Physical Exam

On exam in the ER resuscitation bay on the day of admission, the 1. Identifcation patient presented with a of 113, otherwise he was afebrile, and vital signs were stable with a GCS of 9. He was obtunded and A 29-year-old male presented to the Emergency Department (ED) or verbally incoherent. He had horizontal to light. Abdomen Hamilton General Hospital with a decreased level of consciousness, a was soft and only moderately distended. Pain level was not accurately Glasgow Score of 9, and severe respiratory distress. assessed due to his lowered level of consciousness however there was no overt grimacing or guarding in response to palpation. 2. History of Presenting Illness 4. Past Medical History On presentation, the patient was obtunded and unable to give a history. In the ED, he had tonic-clonic consistent with Te patient had a history of asthma, drug and alcohol abuse, and cocaine toxicity. His family stated that he had recently returned from cataracts second to steroid use. Te patient was an MMA fghter. a trip to Cost Rica; the friend with whom the patient had traveled to Current medications included Percocet, Ventolin and Flovent. Costa Rica with had been admitted to Hamilton General Hospital with cocaine toxicity within days of his return. Te patient remained 5. Investigations non-verbal after the seizures had ceased and the urine drug screen tested positive for cocaine. Bloodwork revealed a white count of 16.5, hemoglobin of 154 and platelets of 222. Electrolytes were within normal limits, aside from

VOLUME 14, ISSUE 1 | 2017 Foreign material in the gastrointestinal tract: medical care and review of toxidromes 21

mild hypokalemia at 3.3. Extended electrolytes and liver enzymes 6. Assessment and Plan were unremarkable. Creatinine was elevated at 146. Urine drug screen test was positive for cocaine but negative for ethanol. Te patient was a 29-year-old male who had recently returned from a trip to Costa Rica with a friend, who presented to the ED of Juravinski A chest x-ray at the time of admission showed some changes with seizures, positive urine screen for cocaine and abdominal x-ray consistent with aspiration pneumonia. CT scan of the head on date demonstrating ingested packets. His friend was admitted to Hamilton of admission to evaluate altered level of consciousness demonstrated General Hospital with similar presentation of cocaine intoxication and no abnormalities. swallowed packets of cocaine. He had a history of drug and alcohol Case Reports abuse, and was a MMA fghter. An abdominal x-ray revealed multiple packets within the stomach, several packets in the right colon and a visible packet in the distal After clinical and physical assessment, in addition to investigations transverse colon (Figure 1). and imaging, it seemed likely that one of the packets had leaked and as a result, the patient sufered from cocaine intoxication. Given his low GCS, the ICU team intubated him and emergency department physicians inserted a central line. Discussion between ICU physicians and the general surgery team agreed that surgery was indicated in this case; the surgery was arranged for the same afternoon as a Priority-1 case.

7. Management

A laparotomy was performed: no evidence of bowel perforation was found in the peritoneal cavity and the small bowel was collapsed. Palpation of the stomach revealed multiple foreign bodies. Several yellow packets were removed by gastrotomy; most were intact but incomplete fragments of packaging material suggested several packets had previously ruptured. Careful palpation of the stomach lumen, from the GE junction to the duodenum, was done to ensure all foreign bodies were removed. Te stomach was suctioned empty.

Palpation of the colon revealed 2 packets near the splenic fexure and several packets in the ascending colon. Each packet was milked distally down to the rectum and extracted per anus. No foreign bodies were palpated in the small bowel. After retrieval of the packets intra- operatively, many of which had ruptured, the patient did well and was transferred post-operatively to the intensive care unit (ICU) in stable condition.

In recovery, the patient requested that the notes from this hospitalization not be transferred to his family physician; while he was informed that earlier notes might have already been sent over, the decision to disclose information to his circle of care was left to his discretion and care was taken to prevent further information from being transferred.

8. Outcome

Upon discharge, the patient was advised to return to the hospital should he experience any worsening abdominal pain, , inability to tolerate oral intake and should follow up with his surgeon the following week. Discharge medications included Ibuprofen 400mg PO TID for 7 days and Acetaminophen 650mg PO q4h PRN. At the time of discharge, the patient had stable vitals, good bowel Figure 1: Plain abdominal x-ray revealing multiple packets, arrows point to function, and was eating, drinking and mobilizing well. Te patient visible cocaine packets in the small bowel prior to surgical exploration. was discharged on post-operative day 4.

WWW.MUMJ.ORG 22 McMASTER UNIVERSITY MEDICAL JOURNAL

DISCUSSION Although early body packers were largely young males, the profle of body packers is changing to include pregnant women and children. Te In 1981, the term “Body Packer Syndrome” was coined to describe use of children as vehicles have been described in two separate incidents mortality from drug toxicity following ingestion for transportation.2 Te involving two boys age 12 and 16; one child presented to clinicians clinical outcome of body packing can be unpredictable and methods of after failing to connect with his handlers, the other was discovered removing drug packets such as surgery, enemas, central lines and food unconsciousness after a heroin packet ruptured.13 Te use of pregnant deprivation can carry potentially serious complications.3 Typically, drugs women as transport has also been described in literature.14 are packaged in latex gloves, condoms and rubber balloons. Te typical Case Reports drugs carried by body packers are heroin, cocaine and cannabis, however Mortality rates are low for surgeries performed due to obstruction, , 3,4-methylene-dioxymethamphetamine (ecstasy) and however palpating the bowel does not confrm that all packets have lysergic acid are also transported.4 Te smuggling of such been removed. A plain postoperative abdominal radiography should as mescaline and psilocybin is uncommon.5 Body packers will usually be performed to minimize complications of wound .2 Cocaine carry about 1kg (2.2 lb) of drug, typically separated into 50-100 drug metabolites may cause false-negative results, therefore urine screening containers of 8 to 10g each prior to departure; however, cases of more does not present with high diagnostic value for body packers who are than 200 packets have been reported.2,6,7 asymptomatic. Plain abdominal radiography has a far higher specifcity of 97% in cases where packets are undetectable by urine screening and Following ingestion, anti-motility drugs such as Loperamide or a sensitivity of 85-90%.10,15 False positives may result from inspissated Diphenoxylate are used to slow gastrointestinal motility, and pro- stool, bladder stones or intra-abdominal calcifcations.7 Plain motility agents such as magnesium hydroxide or magnesium citrate radiography and ultrasonography are good tools for screening or rapid are used on arrival in order to expel the containers. Although serious assessment, but contrast-enhanced abdominal computed tomography complications are now rare due to advancements in detection, the (CT) or barium-enhanced radiography may provide more defnitive diagnosis of body packer should be a consideration for acutely answers due to higher sensitivity.7 unwell international travellers, particularly when accompanied by unconsciousness, , collapse, gastrointestinal symptoms or other Asymptomatic patients may be treated conservatively with pro-motility symptoms of toxidrome intoxication as discussed in this report. agents and laxatives until all packets are passed and confrmed by imaging. Te current standard of treatment is polyethylene glycol, an Persons who transport drugs are typically detected for three reasons: osmotic laxative that works by retaining water in the stool leading to suspicious behavior, drug toxicity from packet leakage or intestinal more frequent, softer bowel movements. Te use of PEG has been obstruction. Although most body packers are asymptomatic, suspicious shown to prevent package rupture.10,15 For asymptomatic patients, there behaviors include shaking hands, perspiring excessively, wearing clothing is no consensus on the timing of surgical intervention; the literature that disguises body contours, expressing inconsistent statements, sitting suggests times varying from 27 hours to 7 days.10 In a series of 50 motionless, and refusing food and drink during long journeys.8,9,10 patients who had swallowed packets of cocaine, there were no deaths According to a 2003 report from Traub et al, in most jurisdictions, and all patients were managed conservatively.6 travelers “reasonably suspected” of body packing may be detained for 24 to 48 hours for the initial investigation, which may include an Although the overall goal of healthcare providers is packet passage, abdominal radiograph, although Customs ofcials may consult with the patients may also receive symptomatic treatment based on clinical US Attorney’s ofce if they wish to hold suspects for more than 8 hours. fndings. As packets tend to leak prior to rupturing, clinical should be identifed early to prevent catastrophic efects.7 In some cases, law enforcement ofcers identify body packers and refer Abdominal exam may reveal palpable packets or distention and rectal them to physicians for evaluation, management and packet recovery; exam may be helpful in identifying packets close to passage, however however, in many cases, patients present to clinicians with symptoms the physical exam is not as useful as clinical diagnosis, which includes related to packet rupture, hemorrhage, intestinal obstruction or other signs and symptoms such as hydration, size and reaction, vital complications.11 Cocaine intoxication can be fatal; the acute lethal signs, neurological status, bowel motions and urinary retention4, as well oral dose is 1.2g however death has been reported after ingestion of as imaging.7 Drug specifc toxidromes may shed light on management only 20mg.12 It is difcult to assess the number of body packers who strategy in the emergency room and in the operating room and wards: attempt to travel into Canada and other countries. In a study of the patients overdosed on Heroin may manifest in coma, respiratory greater New York City area from 1990 to 2001, internal concealment depression or and , while patients overdosed on cocaine of drugs resulted in at least 50 deaths.11 Tere was a 60% increase in or amphetamines may present with diaphoresis, , seizure, body packer arrests at New York’s John F Kennedy Airport following , pupil dilation and coma.4 the terrorist attack on September 11, 2001, however it is unclear whether this increase is due to increased surveillance, trafc, demand or In a study by de Beer et al that clinically evaluated 70 body packers, 5.1% a combination of factors.11 Due to the sensitive and difcult to monitor demonstrated intestinal obstruction, 4.2% hemorrhagic complications nature of drug concealment, there is limited availability of more recent and 2.3% convulsions. Surgery is indicated when conservative methods body packing statistics in the United States and other countries. fail to pass the packets after 5 days, or in cases of gastrointestinal perforation, obstruction and drug toxicity.

VOLUME 14, ISSUE 1 | 2017 Foreign material in the gastrointestinal tract: medical care and review of toxidromes 23

Toxidromes are recognizable symptoms and signs (syndromes) caused References by toxicity related to a specifc drug or class of drugs. Te physiologic and pharmacologic efects are attributable to particular classes including 1. Deitel M, Syed AK. Intestinal obstruction by an unusual foreign body. Can , opiate, , cholinergic, and hypnotic Med Assoc J. 1973;109:211–212. and plants. Many toxidromes may be identifed by history or with a 2. Kucukmetin NT, Gucyetmez B, Poyraz T, Yildirim S, Boztas G, Tozun N. thorough physical examination. Rapid assessment and treatment is Foreign Material in the Gastrointestinal tract: Cocaine Packets. Case Rep critical in the management of patients presenting with an overdose.17 Gastroenterol 2014; 8(1):56-60. Common toxidromes are listed in Table 1. 3. Prabhu R, Ne’eman A, Bier K, Patel N. Radiology of body packers: the Case Reports detection of internally concealed illegal materials. 4. Wong GCK, Lai KK, Chung CH. Management of body packers in the CONCLUSION emergency department. Hong Kong Journal of Emergency Medicine 2005; 12(2): 112-118. Since frst reported in the 1970’s, drug trafcking by body packers is 5. Pinkto A, Reginelli A, Pinto F, Sica G, Scaglione M, Berger FH, Romano L, a growing international concern. Although there has been substantial Brunese L. literature published on body packers, there is still uncertainty 6. Caruana, D.S., Weinbach, B., Goerg, D. & Gardner, L.B. Cocaine-packet regarding both medical and surgical management. Generally, ingestion. Ann Intern Med 1984, 100: 73-74. conservative management is appropriate in the majority of patients. 7. Traub SJ, Hofman RS, Nelson LS. Body packing-the internal concealment Surgical intervention should be reserved for those who fail to pass of illicit drugs. N Engl J Med.2003;349:2519-2526. drug packets medical means, or if evidence of drug toxicity occurs. 8. Schaper A, Hofmann R, Bargain P, Desel H, Ebbecke M, Langer C. Surgical treatment in cocaine body packers and body pushers. Int J Colorectal Dis. Te carriage of illegal substances in the gastrointestinal tract is an 2007;22:1531–153 increasingly popular and dangerous method of smuggling drugs. 9. Koehler SA, Ladham S, Rozin L, Shakir A, Omalu B, Dominick J, Wecht Although serious complications are now rare due to advancements in CH. Te risk of body packing: a case of a fatal cocaine overdose. Forensic Sci detection, the diagnosis of body packer should be a consideration for Int. 2005;151:81–84 acutely unwell international travellers, particularly when accompanied 10. Yegane RA, Bashashati M, Hajinasrollah E, Heidari K, Salehi NA, Ahmadi by unconsciousness, seizure, collapse, gastrointestinal symptoms or M. Surgical approach to body packing. Dis Colon Rectum. 2009;52:97–103 other symptoms of toxidrome intoxication as discussed in this report. 11. Traub SJ, Ewald ME, Grayzel J. Internal concealment of drugs of abuse (body packing). Retrieved March 29, 2017 from the World Wide Web: http://cursoenarm.net/UPTODATE/contents/mobipreview. htm?7/59/8127?source=see_link 12. Wade A (ed). Marindale, Te Extra Pharmacopoeia. Te Pharmaceutical Findlay Creek Press 1977; 27: 871-872. Medical Centre 13. Traub SJ, Kohn GL, Hofman RS, Nelson LS. Pediatric “body-packing.“ Arch Pediatr Adolesc Med 2003;157:174-177 We are expanding our practice opportunities 14. Greenberg MI, Shrethra M. Management of the pregnant body packer. J and invite 8 family physicians and specialists Toxicol Clin Toxicol 2000;38:176-177 abstract. keenly interested in developing their practice. 15. Beckley I, Ansari NA, Khwaja HA, Mohsen Y. Clinical management of cocaine body packers: the Hillingdon experience. Can J Surg. 2009;52:417–421 Our new 6500 sq foot medical centre is located 16. de Beer SA, Spiessens G, Mol W, Fa-Si-Oen PR. Surgery for body packing on the 6th floor @ 1081 Carling Avenue. This in the Caribbean: a retrospective study of 70 patients. World J Surg. 2008;32:281–285. discussion 286–287. medical centre will provide the same high stan- 17. Rudis MI. Pharm 545 – Terapeutics III Autonomic Nervous System dard of patient care the physician group have (ANS), Case 4 Toxidromes: ANS Cases from the Emergency Department. and continue to provide at our very successful University of Southern California 1999. Retrieved March 20, 2017 from FHO @ Findlay Creek Medical Centre. Locums the World Wide Web: http://www.usc.edu/hsc/pharmacy/curriculum/l3/ are welcome. phar545/ToxidromeCaseKey.pdf

1081 Carling Avenue, 6th Floor (Next to the Ottawa Hospital Civic Campus) Ottawa, Ontario

You are invited to contact us at (613) 277-7010 www.ottawamedicalcentre.com

WWW.MUMJ.ORG 24 McMASTER UNIVERSITY MEDICAL JOURNAL

Table 1: Table of Common Taxidromes.

Toxidrome Examples Mental Status Overdose signs and Treatment symptoms

Anticholinergic • , “Hot as a hare” Physostigmine (eg. TCAs) , chorea, “Blind as a bat” (reversible • seizures, coma “Dry as a bone” acetylcholinesterase

Case Reports (eg. Diphenhydramine) “Red as a beet” inhibitor) • Antiparkinsonians “Mad as a hatter” • “The bowel and bladder • Antispasmodics lose their tone and the • Belladonna alkaloids heart goes on alone” (eg. ) • • Carbamazepine • Dry skin • Cyclobenzaprine • Vasodilation (Flexeril) • • • Tachycardia •

Cholinergic • Altered mental “DUMBELS” Atropine and related • Natural plants: status, weakness, • Diaphoresis, anticholinergic drugs mushrooms, trumpet , , Decreased as antidotes to nerve flower drowsiness, coma BP agent poisoning • Anticholinesterases: • Urination physostigmine • Miosis • Insectisides • Bronchospasm, (organophosphates, Bronchorrhea, carbamates) Bradycardia • Nerve gases (anti- • Emesis, Excitation of acetylcholinesterase) skeletal muscles • Pilocarpine, • Lacrimation • Salivation, Seizures

Bradycardia, , , miosis

Extrapyramidal • Major tranquillizers Hypokinetic Symptoms of • Antipsychotics (eg. In Parkinson’s akathisia respond to disease and after discontinuation of short-term exposure APM coupled with to dopamine-blocking anxiolytic medications drugs) or blockers • Dysphonia • Dysphagia Dystonic reactions respond to Hyperkinetic (ie. anticholinergic and Huntington’s disease and antiparkinsonian after chronic exposure agents to dopamine-blocking drugs) • Motor restlessness • Akathisia • Dyskinesia • Dystonia (muscle spasms, laryngospasm, trismus, oculogyric crisis, torticollis)

VOLUME 14, ISSUE 1 | 2017 Foreign material in the gastrointestinal tract: medical care and review of toxidromes 25

EtOH EtOH Confusion, • Hypothermia Treat hypoglycemia unpredictable • with 50ml 50% behavior and • Respiratory dextrose solution stupor, sudden depression (less than and saline flush lapses into 8 breaths/min) (unresponsive to and out of • Pale, bluish, cold and glucagon) unconsciousness clammy skin due to

or semi- oxygen insufficiency Thiamine to prevent Case Reports consciousness • CNS depression Wernicke-Korsakoff with associated • and syndrome alcoholic , • Metabolic seizures deragements Apply hemodialysis if (lactic acidosis, blood concentration ketoacidosis, acute >400mg/dL and renal failure) especially if there is metabolic acidosis

Opioids • Clonidine Sedation, Shallow respirations, Naloxone • Fentanyl confusion, coma hypotension, bradycardia, • Heroin hypothermia, miosis Treatment for • Methadone dependence: • Morphine Decreased bowel sounds, Methadone and • Oxycodone hyporeflexia buprenorphrine, • Tramadol supported detoxification or oipiod antagonists ie. Naltrexone

Sedative/ Benzos, Sedation, Hypothermia, Decontamination, Hypnotic confusion, hypotension, CNS Supportive care delirium, , depression, bradypnea, coma ataxia, dysthesias, blurred Note: rarely vision, nystagmus, miosis flumazenil, induces seizures Similar to opiates

Sympathomimetic Cocaine, amphetamines Cocaine, Tachycardia, , amphetamines hypertension, mixed alpha/beta hyperthermia, mydriasis blockade

Tremor, warm skin, Secondary treatment diaphoresis, hyperactive of MI, CVA, rhabdo bowel sounds

Reference: https://medicine.ucsf.edu/education/resed/Chiefs_cover_sheets/toxidromes.pdf

WWW.MUMJ.ORG