ACR Codes: 7.5
Illicit drug importation into the United States occurs via several channels. In terms of acute medical consequences, smuggling of cocaine by body packers is most commonly associated with drug toxicity and fatality. The body packer is an international smuggler who ingests carefully packaged drugs in order to export them from their country of origin. The goal is avoidance of detection by law enforcement agencies as well as retrieval once the target import country is reached. While care is taken to ensure safe transit through the gastrointestinal tract without rupture, these measures are not always effective. Rupture then leads to acute cocaine intoxication and in turn, the morbidity and mortality associated with such an overdose.
Oral ingestion of small amounts of cocaine often has little toxicity because gastric acid hydrolyzes the drug to its inactive metabolite -- benzoylecgonine. However, rupture of a cocaine packet in the bowel may have significant morbidity and mortality. In patients with suspected oral ingestion or suspected body packing, monitoring for signs and symptoms of acute cocaine intoxication is imperative.
Toxic effects are most apparent in the cardiovascular and central nervous systems. Signs of acute cocaine intoxication include tachycardia, hypertension, mydriasis, and agitation. Patients with acute cocaine intoxication may present with signs/symptoms such as altered mental status, chest pain, syncope, palpitations, dyspnea, abdominal pain and seizures. Life-threatening complications include cardiac arrhythmias, myocardial infarction, cardiogenic shock, seizures, rhabdomyolysis, metabolic acidosis, hyperpyrexia, and intracranial hemorrhage.
Management of patients suspected of body packing in terms of observation time remains unclear. Many of these patients remain asymptomatic, and there is no clear relationship between quantity of cocaine ingested and the development of clinical symptoms. There is currently no consensus on suggested observation periods for these patients and proposed times range from 6-72 hours. Multiple case reports indicate that cocaine body packers can develop symptoms of acute cocaine intoxication at least 24 hours after ingestion, occasionally leading to death.
In terms of imaging, there is currently no gold standard for imaging patients suspected of body stuffing or body packing. However, computed tomography (CT) is generally seen as the best technique for packet detection although false negatives have been reported. Recent data indicates that unenhanced (non-contrast) multi-detector CT without bowel preparation is a fast, reliable and reproducible method for detection of ingested packets. Detection is improved by viewing at lung settings (window width 1000 Hounsefield units (HU), window level â€“700 HU) in addition to the usual abdominal CT settings (window width 350 HU, window level 50 HU). On abdominal radiography, packets may be visualised as oval or round soft tissue densities highlighted by a gas halo. Sensitivity of abdominal radiography is reported as 47-95% with supine radiographs providing superior images than erect.
Radiological signs: Double condom sign (air trapped in between packet layers from wrapping technique or fermentation), rosette sign (air trapped in packet knots)
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