Recently we treated
a patient with a potentially fatal overdose of cocaine secondary to a large
poorly sealed packet placed in her vaginal canal. I thought it would interesting to investigate
the complications and define the various methods by which people attempt to
transport and conceal illicit substances.
The majority of
poisoned patients from illicit substances, the most common being heroin and
cocaine, are treated in the emergency department. However it is not uncommon that while being
pursued by law enforcement or during the ingestion of illicit substances a
patient experiences trauma or injury that lead to their transport to a trauma
center.
First we must define
body “packing” vs “stuffing” as the consequences and treatment of each vary. Body “packers” are typically people
transporting very large amounts of substances.
They are commonly referred to as “drug mules”. This is the method by which people transport
illicits across country borders and on airlines. Drugs are often double wrapped in condoms,
dipped in water, and swallowed whole. It
is not uncommon for “packers” to be transporting over 100 packets of illicit
substance. Once they reach their
destination, they ingest a cathartic and packets are subsequently removed. Drug “stuffers” in contrast include people
who either ingest or place a container containing an illicit in a body orifice
in an attempt to avoid detection by authorities. The amount of drug is usually small and
nonlethal. Our patient would be
considered a body “stuffer” however suffered additional consequences due to the
uncharacteristic large volume of drug in her possession.
When treating a
patient who is suspected of “packing” or “stuffing” illicit substances it is
importance to attempt to ascertain the substance they were transporting. Those transporting heroin may suffer
respiratory depression and somnolence but rarely experience more serious
consequences. They should receive
naloxone as needed and be clinically observed until symptoms of intoxication
subside. Those transporting cocaine on
the other hand should be treated much more aggressively. A typical packet of cocaine ingested by a
body packer contains approximately 10 grams of cocaine, ten times the lethal
dose as described by Traub et al in a 2003 New England Journal of Medicine
article. A patient suspected of
“packing” cocaine who exhibits symptoms of poisoning including agitation,
hyperthermia, hypertension, seizures, or cardiac dysrhythmias should
immediately be taken for operative removal of cocaine packets to prevent rapid
clinical deterioration as the rupture of a single packet can cause death. Cocaine “stuffers” can be managed
conservatively with aggressive cooling measures, benzodiazepines, phentolamine
for hypertensive emergencies and cardiovascular support and correction of
arrhythmias if needed (Marx 2009).
Our patient had in
her possession approximately 10 grams of cocaine, an amount larger than
ingested by the typical “stuffer”. A
thorough physical exam revealed the location of the cocaine wrapped loosely in
a plastic baggie which upon removal was noted to be leaking a large amount of
cocaine. Absorption of cocaine across
the vaginal mucosa can be as rapid as intravenous absorption therefore
explaining her rapid clinical deterioration.
She required ventilator support with intubation, vasopressor support due
to myocardial stunning, and sodium bicarbonate therapy for cardiac dysrhythmias. She was admitted to the MICU and after 24
hours was extubated, downgraded to the medical floors and subsequently
discharged neurologically intact.
Traub SJ, Hoffman RS, Nelson LS: Current
concepts: Body packing—the internal concealment of illicit drugs. N
Engl J Med 2003; 349:2519.
McCarron MM, Wood JD: The
cocaine body packer syndrome. JAMA 1983; 250:1417.
Marx: Rosen's
Emergency Medicine, 7th ed. 2009.
courtesy of Dr. Philip Rohde
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