Category: Dept. Docs.

Concealed Illicit Drugs

Background

Those suspected of concealing illicit drugs often present near ports and borders however they can present to any ED or be brought in by the police.

Body Packers – Swallow large quantities of well packaged drugs to smuggle them into countries or institutions.  These are often well manufactured with a low risk of rupture but the potential for serious toxicity if rupture occurs.

Body Stuffers – Swallow small quantities of poorly packaged illicit substances often at the point of arrest to conceal them. These have a much high risk of package rupture but involve smaller quantities of substances.

 

Investigations

Authorisation for an intimate search or radiological investigation must come from an inspector or higher with written consent from the patient.

Intimate searches must be carried out by a police surgeon but require immediately available resuscitation facilities therefore may be conducted in the ED. ED physicians should not handle the drugs at any time.

AXR or low dose CT scanning can be used to detect concealed packages in Body Packers.

 

General Management

Try to obtain a history of what and how much has been concealed

Look for toxidromes suggestive of package leak – treat as per Toxbase

  • Cocaine: Tachycardia, hypertension, agitation, diaphoresis, dilated pupils, hyperpyrexia, seizures, chest pain, arrhythmias and paranoia.
  • Heroin: pinpoint pupils, respiratory depression, decreased mental state, decreased bowel sounds
  • Amphetamines : – Nausea, Vomiting, Dilated Pupils, Tachycardia, Hypertensions, Sweating, Convulsions and the development of non-cardiogenic pulmonary oedema

 

Toxicology screens (urinary/blood) should not be used to guide management or discharge decisions (Level 5 evidence).

 

Body Stuffers & Pushers should be observed for signs of toxicity for a minimum 8 hours, consider activated Charcoal

Body Packers with positive imaging who are asymptomatic can be discharged back to police custody for monitoring. Bowel preparation such as Cleanprep or movicol can be used.

 

Body Packers with signs of cocaine or amphetamine toxicity or signs of obstruction/ileus require urgent surgical intervention.

Body packers with signs of Heroin toxicity should be treated with Naloxone infusion as per toxbase guidelines

All patients transferred to police custody should receive a discharge letter, including
Suspected Internal Drug Traffickers.

 

Algorithms

 

 

 

Full RCEM Guide

Self-Discharge

Still in the ED

Left ED

  • Assess the risk, do we need to:
  • Inform Nurse-in-Charge
  • Add to handover board if actions are required by the in-hours team
Searchs: abscond, absconded, did not wait, didnt wait, didn’t wait

Suspected Cauda Equina Syndrome CES

1. Red Flags: Has the patient developed any of the following?

  • Difficulty initiating micturition or impaired sensation of urinary flow
  • Altered perianal, perineal or genital sensation S2-S5 dermatomes – area may be small or as big as a horses’ saddle (subjectively reports or objectively tested)
  • Severe or progressive neurological deficit of both legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
  • Loss of sensation of rectal fullness
  • Sexual dysfunction (achievement of erection or ability to ejaculate, loss of genital sensation)

If Yes to ANY proceed to 2.

If NO to ALL consider other diagnosis and possibility of GP follow-up

Read more

Massive Transfusion Pathway

In the case of patient with Massive Haemorrhage weather that be from Trauma, Surgical, O&G, UGIB, you can activate the MTP

Remember:

  • Do the Basics – don’t forget ABCD
  • Inform Transfusion and get someone to run a G&S sample down
  • FFP can take up to 45min and platelets come from Leeds
  • If you no longer need the MTP – inform transfusion and return products ASAP
major haemorrage

PDF:MTP