6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
A) ACTIVATED CHARCOAL 1) Activated charcoal adsorbs sympathomimetics and opioids effectively. 2) PREHOSPITAL ACTIVATED CHARCOAL ADMINISTRATION a) Consider prehospital administration of activated charcoal as an aqueous slurry in patients with a potentially toxic ingestion who are awake and able to protect their airway. Activated charcoal is most effective when administered within one hour of ingestion. Administration in the prehospital setting has the potential to significantly decrease the time from toxin ingestion to activated charcoal administration, although it has not been shown to affect outcome (Alaspaa et al, 2005; Thakore & Murphy, 2002; Spiller & Rogers, 2002). 1) In patients who are at risk for the abrupt onset of seizures or mental status depression, activated charcoal should not be administered in the prehospital setting, due to the risk of aspiration in the event of spontaneous emesis.
2) The addition of flavoring agents (cola drinks, chocolate milk, cherry syrup) to activated charcoal improves the palatability for children and may facilitate successful administration (Guenther Skokan et al, 2001; Dagnone et al, 2002).
3) CHARCOAL DOSE a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005). 1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
b) ADVERSE EFFECTS/CONTRAINDICATIONS 1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
6.5.2) PREVENTION OF ABSORPTION
A) RADIOGRAPHY 1) Radiographic detection of the containers may be more difficult in the body stuffer than in the packer (Pollack et al, 1992).
2) Abdominal CT may be required in the patients with protracted symptoms.
B) ACTIVATED CHARCOAL 1) Activated charcoal may adsorb cocaine or other drugs leaking or leaching from 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 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 a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
4) CHARCOAL DOSE a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005). 1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
b) ADVERSE EFFECTS/CONTRAINDICATIONS 1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
C) WHOLE BOWEL IRRIGATION 1) WHOLE BOWEL IRRIGATION may be a relatively safe and effective means of rapid decontamination for the body stuffer, and may be considered in some patients (primarily those who are suspected to have ingested multiple packets) (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 decreases the ability of charcoal to adsorb charcoal in vitro (Makosiej et al, 1993). a) WHOLE BOWEL IRRIGATION/INDICATIONS: Whole bowel irrigation with a polyethylene glycol balanced electrolyte solution appears to be a safe means of gastrointestinal decontamination. It is particularly useful when sustained release or enteric coated formulations, substances not adsorbed by activated charcoal, or substances known to form concretions or bezoars are involved in the overdose. 1) Volunteer studies have shown significant decreases in the bioavailability of ingested drugs after whole bowel irrigation (Tenenbein et al, 1987; Kirshenbaum et al, 1989; Smith et al, 1991). There are no controlled clinical trials evaluating the efficacy of whole bowel irrigation in overdose.
b) CONTRAINDICATIONS: This procedure should not be used in patients who are currently or are at risk for rapidly becoming obtunded, comatose, or seizing until the airway is secured by endotracheal intubation. Whole bowel irrigation should not be used in patients with bowel obstruction, bowel perforation, megacolon, ileus, uncontrolled vomiting, significant gastrointestinal bleeding, hemodynamic instability or inability to protect the airway (Tenenbein et al, 1987). c) ADMINISTRATION: Polyethylene glycol balanced electrolyte solution (e.g. Colyte(R), Golytely(R)) is taken orally or by nasogastric tube. The patient should be seated and/or the head of the bed elevated to at least a 45 degree angle (Tenenbein et al, 1987). Optimum dose not established. ADULT: 2 liters initially followed by 1.5 to 2 liters per hour. CHILDREN 6 to 12 years: 1000 milliliters/hour. CHILDREN 9 months to 6 years: 500 milliliters/hour. Continue until rectal effluent is clear and there is no radiographic evidence of toxin in the gastrointestinal tract. d) ADVERSE EFFECTS: Include nausea, vomiting, abdominal cramping, and bloating. Fluid and electrolyte status should be monitored, although severe fluid and electrolyte abnormalities have not been reported, minor electrolyte abnormalities may develop. Prolonged periods of irrigation may produce a mild metabolic acidosis. Patients with compromised airway protection are at risk for aspiration. D) SURGICAL THERAPY 1) Rarely, intra-abdominal surgery is indicated if bowel obstruction is present, if the patient has severe symptoms of toxicity (primarily from cocaine) 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).
2) Follow-up plain radiography and a barium swallow with small bowel follow-through should be considered in patients who have ingested large numbers of packets (Peake et al, 2009; Olmedo et al, 2001; Hollander & Hoffman, 2002; Olmedo et al, 2001).
3) Heroin body stuffers may be managed nonsurgically using WBI and naloxone. Surgery should be performed if the body stuffer has a bowel obstruction (Jordan et al, 2009; Nelson, 2002; Olmedo et al, 2001).
E) ENDOSCOPY 1) Attempts at endoscopic removal (mainly in body packers) have resulted in spontaneous rupture of packets and this procedure is NOT RECOMMENDED (Peake et al, 2009; 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). Tap water enemas have also resulted in package rupture (Queen & Glauser, 2002; Jonsson et al, 1983); enemas should be avoided (Souka, 1999; McCleave, 1993).
F) CATHARTICS 1) To avoid possible package rupture or deterioration, gentle laxatives which do not directly stimulate the bowel should be considered (McCleave, 1993). Psyllium, sodium sulfate, and bisacodyl suppositories have been used (Queen & Glauser, 2002).
2) Bisacodyl (Dulcolax) or other rectal suppository may be administered to enhance fecal excretion of the packages. Care must be taken not to perforate drug packets which might be in the rectum.
3) CASE SERIES: Utecht et al (1993) present 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).
4) Psyllium hydrophilic mucilloid or other bulk laxative may be given to facilitate passage and removal of packages (Dose: 3.5 grams 2 to 3 times daily).
5) Liquid paraffin or mineral oil may dissolve latex packets and should be avoided (Visser et al, 1998; McCleave, 1993).
6) In a retrospective cohort study of 98 cocaine body stuffers, 7% of patients were treated with magnesium citrate (Sporer & Firestone, 1997).
G) CRACK VIALS 1) Crack vials ingested to avoid arrest have also caused symptomatic intoxication. In a study of 23 patients with a history of having ingested crack vials, four patients developed mild to severe symptomatology (Hoffman et al, 1990).
2) Vials were retrieved in 2 of 3 patients given ipecac, and in 2 of 5 patients treated with whole bowel irrigation (Hoffman et al, 1990).
3) Although vials were ultimately recovered from eleven patients, abdominal radiographies were positive in only two. Thus, radiography may not reveal the presence of crack vials in the gastrointestinal tract (Hoffman et al, 1990).
6.5.3) TREATMENT
A) MONITORING OF PATIENT 1) No specific studies are required for most asymptomatic patients. Urine drug screens may confirm exposure but cannot distinguish recreational use from drug absorption after stuffing.
2) In symptomatic patients, institute continuous cardiac monitoring and obtain serial ECGs.
3) In a patient with signs of toxicity after stuffing a sympathomimetic agent, monitor electrolytes, CBC, CPK, and urinalysis. Obtain a head CT to evaluate for hemorrhage in patients with abnormal mental status.
4) When opioids are stuffed, monitor electrolytes, glucose, pulse oximetry/capnometry, and chest radiograph (if hypoxic).
5) Abdominal x rays are rarely helpful in body stuffers.
B) PSYCHOMOTOR AGITATION 1) INDICATION a) If patient is severely agitated, sedate with IV benzodiazepines.
2) DIAZEPAM DOSE a) ADULT: 5 to 10 mg IV initially, repeat every 5 to 20 minutes as needed (Brophy et al, 2012; Prod Info diazepam IM, IV injection, 2008; Manno, 2003).
b) CHILD: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed (Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008).
3) LORAZEPAM DOSE a) ADULT: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed (Manno, 2003).
b) CHILD: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed (Brophy et al, 2012; Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008).
4) Extremely large doses of benzodiazepines may be required in patients with severe intoxication in order to obtain adequate sedation. Titrate dose to clinical response and monitor for hypotension, CNS and respiratory depression, and the need for endotracheal intubation. 5) In a retrospective cohort study of 98 cocaine body stuffers, 15% of patients were treated with benzodiazepines for agitation (Sporer & Firestone, 1997). C) PROCHLORPERAZINE 1) In a retrospective cohort study of 98 cocaine body stuffers, 4% of patients were treated with prochlorperazine (Sporer & Firestone, 1997).
|