a) TYPE 1 - Loosely packed powder in condoms, toy balloons, or the fingers of latex gloves; two to four layers of condom rubber or other latex-like material; round or cigar shaped; highly susceptible to leakage and rupture. In abdominal radiographs, type 1 packages can be readily identified. These packages may appear as well-defined, circular, white densities. In addition, they may appear as more radiolucent foreign bodies (McCarron & Wood, 1983).
b) TYPE 2 - Multilayer tubular latex, tightly packed powder; possibly machine packaged; may be tied tightly with a smooth tie at each end. Highly stable. Less susceptible to breakage than type 1 packets. In abdominal radiographs, type 2 packages can be readily identified. These packages are similar in density to soft tissue and highlighted by a relatively regular gas halo (McCleave, 1993; McCarron & Wood, 1983).
c) TYPE 3 - Hardened paste wrapped in aluminum foil and overwrapped with three to five layers of tubular latex securely tied at both ends; tightly packed powder. In abdominal radiographs, these smaller, very hard, and irregular-sized packages did not appear as foreign bodies. In this case series, the abdominal films were interpreted as negative in all cases. More resistant to breakage or leaching cocaine (McCarron & Wood, 1983).

1) TOXICITY

1) Patients who develop any signs of drug effect are at high risk for rapid deterioration. Early airway management and aggressive resuscitation should be started at the first sign of drug effect. Patients who have X-ray or CT confirmation of retained packages should be admitted to an ICU setting. Perform continuous cardiac monitoring. If the patient is awake and asymptomatic, administer oral charcoal and initiate whole bowel irrigation with polyethylene glycol (DOSE: ADULTS - 2 liters initially, then 1.5 to 2 liters per hour until rectal effluent is clear and radiography is negative. CHILDREN 6 TO 12 YEARS: 1000 mL/hour; CHILDREN 9 MONTHS TO 6 YEARS: 500 mL/hour.) to hasten the removal of packets. Patients who remain asymptomatic must be observed until all packets are passed. This usually takes 3 to 4 days. Patients can be discharged after having 2 to 3 packet-free stools and negative imaging (plain, barium enhanced abdominal radiographs or CT). There is no perfect imaging modality for detection of packages, and often a combination of modalities is necessary. CT is thought to be more accurate than radiography for detection because of improved contrast resolution. Mild to moderate sympathomimetic exposures can be treated with IV fluids and benzodiazepines. Consult the surgical team early because of the risk of rupture or obstruction. For mild to moderate opioid exposures, respiratory status should be monitored and naloxone administered if clinically indicated. A naloxone infusion may be necessary because of continued drug absorption.

1) Early airway management is imperative for any patient with severe toxicity. For severe sympathomimetic exposures, patients should be aggressively sedated (large doses of benzodiazepines may be necessary), and if this is not effective, patients should be paralyzed and intubated. Patients who develop wide complex dysrhythmias or cardiac arrest should be treated with sodium bicarbonate (1 to 2 mEq/kg IV repeated every 5 minutes, endpoint is arterial pH of 7.45 to 7.55). Immediately involve the surgical team for any patient with signs of packet rupture, obstruction or hemodynamic instability, because of risk for severe toxicity and gastrointestinal necrosis, especially with sympathomimetic agents. Severe toxicity from opioid overdose can be effectively reversed with naloxone boluses or an infusion titrated to reverse mental status and respiratory depression. If a patient arrives intubated, do not administer naloxone as this may precipitate withdrawal. Allow the patient to metabolize the opioid while providing meticulous symptomatic and supportive care.

1) PREHOSPITAL: Activated charcoal can be administered to asymptomatic patients, but the risks and benefits of administration must be weighed on a case-by-case basis. Activated charcoal adsorbs sympathomimetics and opioids effectively. Activated charcoal can be utilized in any patient who presents with normal mental status or if the airway is protected.
2) HOSPITAL: Activated charcoal can be utilized in any patient who presents with normal mental status or if the airway is protected. Gastric lavage is contraindicated as it is usually not effective, and may perforate any packets in the stomach. Whole bowel irrigation is effective. Administer polyethylene glycol solution to patients who are alert or in whom airway is protected. DOSE: ADULTS - 2 liters initially, then 1.5 to 2 liters per hour until rectal effluent is clear and radiography is negative. CHILDREN 6 TO 12 YEARS: 1000 mL/hour; CHILDREN 9 MONTHS TO 6 YEARS: 500 mL/hour. Follow closely for electrolyte imbalance and monitor mental status and risk of aspiration.

1) Intubate patients not responsive to naloxone or who are seizing, hemodynamically unstable, agitated, or obtunded.

1) Patients who present with QRS widening or wide complex tachycardia after packing cocaine or cocaine containing products, may be treated with sodium bicarbonate (1 to 2 mEq/kg bolus; repeat as needed to maintain arterial pH between 7.45 and 7.55). Monitor acid-base status and serum sodium, as aggressive sodium bicarbonate therapy may cause alkalemia and hypernatremia. Treat seizures with benzodiazepines.
2) Patients who develop opioid toxicity can be treated with the opioid antagonist naloxone (0.4 mg IV and titrate to effect). A naloxone infusion may be necessary due to prolonged drug absorption and can be started at 0.4 to 0.8 mg/hour in normal saline or 5% dextrose titrated to clinical effects.

1) The most commonly packed drugs are not effectively removed by hemodialysis or hemoperfusion.

1) HOME CRITERIA: Body packers should never be managed at home, airport or jail.
2) OBSERVATION CRITERIA: Patients with confirmed packets by radiography should be observed until the passage of all packets was confirmed by negative radiography (plain, barium enhanced abdominal radiographs or CT) and 2 to 3 packet-free stools; however, this is not a guarantee that all packets have passed and stool can obscure detection. The sensitivity for plain radiography is approximately 85% to 90% and thought to be higher with barium enhanced radiography or CT.
3) ADMISSION CRITERIA: All suspected body packers should be admitted to an ICU setting because of a potential for packet rupture and the rapid deterioration of a patient.
4) CONSULT CRITERIA: Consult a poison center or medical toxicologist for assistance in managing any symptomatic body packer. Consult with surgical team early as there is a potential for packet rupture or gastrointestinal obstruction.

1) May occur when patients are not monitored closely or are discharged prematurely. Despite the inherent risks of anesthesia and surgery in patients with severe toxicity from ruptured packets, the immediate surgical intervention for removal of packets and their contents offers these patients the best chance of survival.

a) SYMPATHOMIMETICS (PRIMARILY COCAINE): Mild overdose patients often present with mild tachycardia and hypertension. Patients with moderate to severe toxicity will often present with severe tachycardia, hypertension, hyperthermia, agitation along with aggression, seizures and cardiac dysrhythmias.
b) OPIOIDS (PRIMARILY HEROIN): Patients with mild toxicity may present with mild CNS/respiratory depression. In moderate to severe exposures, patients will present with respiratory/CNS depression, hypoxia, hypotension, hypothermia, and respiratory failure.
c) HALLUCINOGENIC AMPHETAMINES: In general, most cases of MDMA and MDEA toxicity result in mild symptoms that can include fatigue, difficulty concentrating, agitation, hypertension, tachycardia, mydriasis, trismus, and diaphoresis. Occasionally, intense dysphoria (depression, anxiety), confusion, or delirium can occur. Severe overdoses appear to follow a clear pattern of toxicity characterized by hyperthermia, disseminated intravascular coagulation (DIC), rhabdomyolysis, acidosis, hyperkalemia, dysrhythmias, seizures, and acute renal failure. Severe toxicity can develop after typical recreational doses. Ecstasy-associated (MDMA) morbidity and mortality have been related to hyponatremia, dehydration, hyperthermia, hypertensive crisis, and cardiac dysrhythmias.
d) Patients may also present with signs of an anticholinergic toxidrome (mydriasis, tachycardia, decreased bowel sounds, and dry/flushed skin) as these agents are often ingested to delay the passage of packets.

1) Bowel obstruction and laceration and mediastinitis have been reported (Brown et al, 2002; McCleave, 1993).
2) CASE REPORT - A 38-year-old intravenous drug abuser developed an acute small bowel obstruction secondary to an impacted intraluminal heroin balloon in the mid jejunum (Brown et al, 2002).
3) CASE SERIES - In a series of 50 deaths in body packers in New York City, 6 patients developed bowel obstruction and/or bowel perforation, all of these cases involved opioids (Gill & Graham, 2002).
4) In one study, 11 cases of body packers with bowel obstruction were identified. Eight of these patients had no underlying gastrointestinal abnormalities. In these patients, the most common site (n=5) of obstruction was the distal ileum (a few centimeters short of the ileocecal valve). Other sites of obstruction were the stomach (n=2), and the sigmoid colon (n=1). Three cases had underlying predisposing pathology; one with previous appendectomy and adhesions, another with Meckel's diverticulum, and one with benign distal esophageal stricture (East, 2005).

1) WITH POISONING/EXPOSURE

1) A 26-year-old woman at 32 weeks gestation developed severe cocaine toxicity after body packing (seizures, acidosis, apnea, refractory ventricular dysrhythmias). Perimortem cesarean section was performed, and the neonate had apgar scores of 2, 4, and 5 at 1, 5 and 10 minutes respectively. At one year follow-up the child had neurodevelopmental delays. The mother died despite aggressive care; autopsy revealed uterine ischemia, and 157 packets containing 830 g cocaine, one of which had ruptured(Cordero et al, 2006).

1) CBC, electrolytes and urinalysis may be indicated.
2) Cardiac monitoring is indicated in all patients.

1) Rapid urine testing for drugs of abuse may assist in determining the packet(s) content (Nelson, 2002); however, because of the poor sensitivity (37% in one large study) of urine testing, it is not recommended as part of the routine evaluation (Traub et al, 2003a). A negative urine drug screen does NOT rule out the possibility of body packing.
2) Monitoring of urine cocaine levels was not reliable for the determination of residual cocaine packets in a study of 30 body-packers. In 6 of 30 cases, urine levels were undetectable for 5 days before complete clearance of packets (Gherardi et al, 1988).
3) Benzoylecgonine was detected in the urine of a husband and wife team of body packers. Urine tests remained positive until day 2 and became negative only with total clearance of packets (Gherardi et al, 1990). The asymptomatic couple swallowed 56 packets of powder wrapped in cellophane and 5 layers of latex, all tied with nonabsorbable surgical ligature.

a) Plain abdominal radiograph should be taken in both the supine and the erect positions. These films may show oval or round soft tissue densities highlighted by a gas halo. These haloes may be caused by air captured in the packages during wrapping, gas passing into the condoms if the rubber is degenerating, or fermentation of the contents. If gas haloes develop during patient monitoring, it may indicate package breakdown (McCleave, 1993). Many packages are radiopaque or have a distinct radiographic characteristic. In some cases, a knot at the end of the packet may be seen as a "rosette" (Schwartz, 2002; Brown et al, 2002).
b) Since one or two remaining packets can be difficult to visualize radiographically after whole-bowel irrigation, enteric contrast material can help detect any remaining packages (Schwartz, 2002).
c) Approximately 85% to 90% of body packers will have positive plain abdominal radiographs (Schwartz, 1998). One study reported the sensitivity of plain abdominal radiography of 47% to 95% in body packers (Sporer & Firestone, 1997); several large series reported a sensitivity of 85% to 90%, however, sensitivity for small number of packets may be lower (Traub et al, 2003a). Abdominal radiographs have a reported false-positive rate of 3.6% and false-negative rate of 1.2% to 33% in detection of body packs, especially in the colon and when constipation is present. The presence of feces tends to obscure package visualization (Souka, 1999; McCleave, 1993).
d) FALSE POSITIVE ABDOMINAL RADIOGRAPH - False-positive results may occur due to copious stool, especially if the patient is constipated, a recent use of gastrointestinal contrast media, or the presence of bladder stones. A body packer had a false-positive abdominal radiograph resulting from intraabdominal calcifications (Traub et al, 2003; Traub et al, 2003a).
e) In one study of opium body packing, the diagnostic value of ultrasonography, plain x-ray and CT scanning was reviewed. Overall, 25 body packers were considered. Ultrasonography did not reveal any clear countable packets; plain abdominal x-ray showed the packets in 12 (48%) patients and abdominal CT scan was positive in 25 (96%) patients (p <0.001) (Zare & Balali-Mood, 2003).

a) CT scan has been reported to be more accurate than radiography in the detection of the drug-filled bags because of its improved contrast resolution and the elimination of projections of overlapping structures. CT can also show the level and severity of an obstruction (Brown et al, 2002).
b) Upper abdominal CT scan and abdominal radiograph with Gastrografin(R) or barium have been reported to result in better visualization (June et al, 2000; McCleave, 1993; Diamant-Berger et al, 1988; Gherardi et al, 1990; Hoffman et al, 1990; Marc et al, 1990; Hartoko et al, 1988). It is recommended that the first radiograph is taken five or more hours after ingestion of the contrast material and further radiographs should be taken daily (McCleave, 1993), and after whole bowel irrigation has been completed.
c) Brown et al (2002) suggested that many packages in the GI may not be detected if the window width and level settings typically employed for abdominal CT (e.g., window width 350 HU, window level 50 HU) are used. In cases of suspected drug packet ingestion, these authors recommended the use of window width and level settings typically used to view lung parenchyma (e.g., window width 1000 HU, window level -700 HU) in addition to those commonly used for abdominal CT (Brown et al, 2002).
d) In a pilot study with 5 volunteers, Hibbard et al (1999) used non-contrast spiral CT scans 2 to 4 hours after ingestion of a placebo wrapped in plastic bags to determine the effectiveness of the CT scans in visualizing the placebo. Foreign bodies, consistent with placebo, were seen in 3 out of 5 CT scans (60%). No definite foreign body was visible with the other CT scans (Hibbard et al, 1999).
e) CASE REPORT - A 38-year-old male developed acute bowel obstruction secondary to an impacted intraluminal heroin balloon in the mid jejunum. Multiple loops of dilated proximal small bowel with air-fluid levels compatible with a proximal-to-mid small bowel obstruction were observed in the abdominal radiographs. The CT scan of the abdomen without oral or intravenous contrast medium revealed moderately dilated loops of proximal jejunum with an abrupt change in calibre in the mid-to-distal jejunum. A sharply defined, almost perfectly round gas-filled structure mimicking a bowel loop was also observed. This heroin-containing balloon seen on CT of the abdomen was not seen on plain radiographs (Brown et al, 2002).
f) In one case report, a helical abdominal CT scan with oral contrast failed to detect a heroin packet in a body packer. An upright abdominal radiograph showed the packet in the right lower quadrant. The patient received continued WBI and ultimately passed the packet within 1 hour (Hahn et al, 2004).
g) In one study of opium body packing, the diagnostic value of ultrasonography, plain x-ray and CT scanning was reviewed. Overall, 25 body packers were considered. Ultrasonography did not reveal any clear countable packets; plain abdominal x-ray showed the packets in 12 (48%) patients and abdominal CT scan was positive in 25 (96%) patients (p <0.001) (Zare & Balali-Mood, 2003).

a) Magnetic resonance does not visualize packets because of the lack of protons (Kersschot et al, 1985).

a) The Kidney Ureter Bladder Radiograph (KUB) is usually positive in body packers; however, KUB is often negative in body stuffers (Eng et al, 1999).

a) Ultrasonography has not been the diagnostic modality of choice for detecting ingested drug packets (Brown et al, 2002).
b) In one study of opium body packing, the diagnostic value of ultrasonography, plain radiographs and CT scanning was reviewed. Overall, 25 body packers were considered. Ultrasonography did not reveal any clear countable packets; plain abdominal radiograph showed the packets in 12 (48%) patients and abdominal CT scan was positive in 25 (96%) patients (p <0.001)(Zare & Balali-Mood, 2003).

a) DIAGNOSTIC FINDINGS/CASE SERIES - To study the imaging characteristics of cannabis, cocaine and heroin in body packers, a retrospective analysis of the images of plain abdominal radiography, computed tomography (CT) and ultrasound (US) was performed in 23 patients. In abdominal plain radiographs and CT, cannabis and cocaine packages were observed as well-demarcated rectangular-shaped high-density shadows surrounded by gas halo ("double condom sign"). Since heroin packages resembled stool masses, they were demonstrated as obscure shadows and were difficult to identify on plain radiographs. In one cannabis patient, US was performed and packages were demonstrated as round echogenic structures with dorsal echo extinctions. The authors concluded that abdominal plain radiography, CT and US are valuable diagnostic modalities to evaluate body packers (Ichikawa et al, 1997).

A) All suspected body packers should be admitted to an ICU setting because of a potential for packet rupture and the rapid deterioration of a patient.

A) Body packers should never be managed at home, airport or jail.

A) Consult a poison center or medical toxicologist for assistance in managing any symptomatic body packer. Consult with surgical team early as there is a potential for packet rupture or gastrointestinal obstruction.

A) Patients with confirmed packets by radiography should be observed until the passage of all packets was confirmed by negative radiography (plain, barium enhanced abdominal radiographs or CT) and 2 to 3 packet-free stools; however, this is not a guarantee that all packets have passed and stool can obscure detection. The sensitivity for plain radiography is approximately 85% to 90% and thought to be higher with barium enhanced radiography or CT.
B) Packet counts and packet-free stools should never be used as the sole determinant that all packets have been passed (Traub et al, 2003a).

1) Activated charcoal adsorbs sympathomimetics and opioids effectively.
2) PREHOSPITAL ACTIVATED CHARCOAL ADMINISTRATION
3) CHARCOAL DOSE

1) Activated charcoal may adsorb cocaine leaking or leaching from cocaine packets, as well as serve as a marker for GI transit. It has been suggested that some packets are semipermeable and do not need to rupture to cause death from cocaine toxicity (Queen & Glauser, 2002; Wetli & Mittleman, 1981).
2) Although activated charcoal has been used in body packers, its spillage into the peritoneum secondary to perforation of the bowel wall or during surgery is of concern (Olmedo et al, 2001).
3) CHARCOAL ADMINISTRATION
4) CHARCOAL DOSE

1) WHOLE BOWEL IRRIGATION may be a relatively safe and effective means of rapid decontamination for the asymptomatic body packer (Olmedo et al, 2001; Betzelos & Mueller, 1991; Hoffman et al, 1990). Activated charcoal should be administered prior to beginning whole bowel irrigation as polyethylene glycol (PEG) solution decreased the ability of charcoal to adsorb drug in vitro (Makosiej et al, 1993).
2) In vitro, cocaine is rapidly hydrolyzed to benzoylecgonine at a pH above 7.4 (Aks et al, 1992). Polyethylene glycol solutions have a pH of 8 and enhance transit from the stomach to the alkaline small intestine, thus potentially diminishing cocaine absorption from leaking packets.
3) However, as benzoylecgonine is not pharmacologically inactive (Brogan et al, 1992; Kurth et al, 1993), it is not clear what clinical effect the intraintestinal hydrolysis of cocaine would have (Konkol & Olsen, 1993).
4) One study reported that WBI with PEG used to treat contraband body packers had no higher complication frequency than other reported methods. There was no correlation between the mean length of hospital stay and either PEG dose, drug type, packet quantity, or packet weight (Farmer & Chan, 2003).
6) CASE REPORT - One patient presented with opiate intoxication after swallowing packets wrapped only in electrical tape. He received activated charcoal and polyethylene glycol (PEG) solution and subsequently developed severe opiate intoxication and pulmonary edema. Endoscopy revealed empty packets in the stomach. The authors postulate that PEG may have increased the solubility of the heroin and diminished its adsorption to charcoal (Utecht et al, 1993).

1) Two body packers received promotility agents, erythromycin (250 mg IV ) and metoclopramide (10 mg IV), and successfully passed drug packets. In one body packer, the use of promotility agents resulted in the passage of a packet that had not progressed after 18 hours of WBI therapy. Promotility agents therapy is absolutely contraindicated in patients with gastrointestinal obstruction (Traub et al, 2003a).

1) Surgery is probably unnecessary unless the cocaine body packer becomes toxic or has bowel obstruction. Most patients can be managed with whole bowel irrigation, charcoal and observation (Silverberg et al, 2006; Souka, 1999; Caruana et al, 1984; McCarron & Wood, 1983). Intra-abdominal surgery is indicated if bowel obstruction is present or if abdominal radiography shows residual packets remaining in the gastrointestinal tract not removed by WBI (Peake et al, 2009; Queen & Glauser, 2002; Olmedo et al, 2001; Hollander & Hoffman, 2002; Olmedo et al, 1999; Souka, 1999). The clinician should be aware that surgery may fail to detect intraluminal drug packets (Olmedo et al, 2001; McCleave, 1993).
2) According to a retrospective review of 4,660 cocaine body packers detected at the Paris and Frankfurt/Main International Airports from 1985 to 2002, 64 cocaine body packers became symptomatic due to rupture of the packets. Of these 64 symptomatic body packers, 20 underwent emergency surgery with a 100% survival rate and no major complications. The other 44 body packers died before they could be treated (Schaper et al, 2007).
3) Follow-up plain radiography and a barium swallow with small bowel follow-through, or abdominal CT scan should be performed in all patients (Peake et al, 2009; Traub et al, 2003a; Hollander & Hoffman, 2002; Olmedo et al, 2001).
4) Heroin body packers may be initially managed nonsurgically using WBI and continuous-infusion naloxone. Surgery should be performed if the body packer has bowel obstruction (Silverberg et al, 2006; Nelson, 2002; Olmedo et al, 2001).

1) Attempts at endoscopic removal have resulted in spontaneous rupture of packets and this procedure is NOT RECOMMENDED (Peake et al, 2009; Silverberg et al, 2006; Queen & Glauser, 2002; McCleave, 1993; Suarez et al, 1977), although in certain circumstances it may be "cautiously attempted" (Hoffman et al, 1990; Sherman & Zingler, 1990), particularly if the packet will not pass through the pylorus (Peake et al, 2009). The use of fiberoptic gastroduodenoscopy to remove drug-filled packets has produced mixed results (Olmedo et al, 2001).

1) Although the use of oil-based laxatives is occasionally recommended, they should not be used; these laxatives reduce the tensile strength and "burst" volume of latex products (Traub et al, 2003a).
2) Liquid paraffin or mineral oil may dissolve latex packets and should be avoided (Visser et al, 1998; McCleave, 1993).
3) To avoid possible package rupture or deterioration, gentle laxatives which do not directly stimulate the bowel have been used, but are not routinely recommended (McCleave, 1993). Psyllium, sodium sulfate, and bisacodyl suppositories have been used but are not generally recommended (Queen & Glauser, 2002).
4) Care must be taken not to perforate drug packets which might be in the rectum.
5) CASE SERIES: Utecht et al (1992) presented a series of 14 patients, nine of whom swallowed heroin-containing packets and five of whom inserted them rectally. Thirteen had evidence of packets on KUB. Bisacodyl suppositories were used to evacuate packets from the rectum. No patient received gastric lavage (Utecht et al, 1993).

1) Cobaugh et al (1997) reported a successful bronchoscopic removal of a cocaine balloon after aspiration (Cobaugh et al, 1997).

1) Tap water enemas have also resulted in package rupture (Queen & Glauser, 2002; Jonsson et al, 1983); enemas should be avoided (Souka, 1999; McCleave, 1993).

1) Monitor electrolytes, CBC, CPK, and urinalysis.
2) Perform radiography imaging including plain, barium enhanced abdominal radiographs and/or CT to document packets and removal of packets.
3) Institute continuous cardiac monitoring and obtain serial ECGs.
4) A negative urine drug screen does NOT rule out the possibility of body packing.