Body packing

Background

Abdominal x-ray reveals multiple, oval radiopaque packets throughout the abdomen.

Body packers, also called "mules", swallow or insert drug filled packets into body cavity, usually to smuggle them across borders
Packets usually made of several layers of latex and outer wax coating
Each packet contains about 10g of drug and body packers ingest between 50 to 100 drug containers at a time^[1]
Sometimes packets are inserted rectally or vaginally
Distinct from Body stuffing (ingestion of illicit drugs while pursued by law enforcement, usually small quantity)

Situations in which body packers present to the ED:
- Asymptomatic but in custody
- Signs of toxidromes from a ruptured packet
- Signs of bowel obstruction or perforation

Asymptomatic patients
- Expectant management, no surgery, close monitoring in ICU until passage of all packets
- Whole bowel irrigation with polyethylene glycol via NGT at 2L per hour
- Activated charcoal more useful in body stuffers
Opioid toxicity
- Naloxone: may require very high doses
  - 2 to 5mg IV initially, repeat 2mg q5min until responsive
  - then total amount required for response should be given every hour as continuous drip
Sympathomimetic toxicity
- Immediate OR for surgical decontamination
- No place for conservative management
- Pharmacologic stabilization appropriate but not definitive, do not delay transfer to the OR
  - Hyperthermia
    - Active external cooling
    - IV benzodiazepines (midazolam 1 to 2mg IV or diazepam 5 to 10 mg IV, rapid escalation in dosing)
  - Hypertension
    - IV benzodiazepines, phentolamine, nitroprusside, nitroglycerin,, or nicardipine
  - Seizures
    - IV benzodiazepines, followed by propofol if needed
  - Ventricular dysrhythmias
    - IV benzodiazepines, followed by hypertonic sodium bicarbonate if wide QRS
Obstruction or perforation
- OR for immediate ex-lap, then advanced imaging study to document a clear GI tract
- Endoscopic removal highly controversial, risk of packet perforation

Admit all to ICU, regardless of symptoms
Complete GI decontamination by contrast CT should be documented prior to discharge
- History is unreliable
- Passage of 2 or 3 packet free bowel movements is not sufficient^[2]

↑ Booker RJ. Packers, pushers and stuffers--managing patients with concealed drugs in UK emergency departments: a clinical and medicolegal review. Emerg Med J. 2009;26(5):316-20.
↑ Rousset P. Detection of residual packets in cocaine body packers: low accuracy of abdominal radiography-a prospective study. Eur Radiol. 2013;23(8):2146-55.