Category: Medical

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 –

  • 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

ECG

Body Stuffers should be observed for signs of toxicity for a minimum 6 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.

Toxidromes should be treated as per toxbase guidelines Toxbase

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

 

Algorithms

 

 

Full RCEM Guide

Rash/Derm Guide

Guide Taken from the Primary Care Dermatology Society(PCDS) other good sourse is DermnetNZ.

A relatively easy way to find out what you’re looking at!

Rash – Apearance
Rash – Site
Lesions
Skin Conditions (DermnetNZ – a bit clunckier)

Trust Dalteparin dosing

Trust Guidance varies slightly from BNF for those patients over 100kg

Non-Pregnant PE/DVT treatment

Dalteparin Cr Clearance >29ml/minDalteparin Cr Clearance 20-29ml/min
Weight (kg)DoseWeight (kg)Dose
<45kg7,500 units OD<63kg5,000 units am
2,500 units pm
45-56kg10,000 units OD63-80kg5,000 units BD
57-68kg12,500 units OD81-98kg7,500 units am
5,000 units pm
69-82kg15,000 units OD99-116kg7,500 units BD
83-100kg18,000 units OD117-134kg10,000 units am
7,500 units pm
101-115kg10,000 units BD135-152kg10,000 units BD
116-140kg12,500 units BD
>140kg15,000 units BD

Pregnant PE/DVT treatment

Weight (kg)Dose
<50kg10,000 units OD
50-69kg12,500 units OD
70-79kg15,000 units OD
80-89kg18,000 units OD
90-109kg20,000 units OD
110-124kg22,500 units OD
125-139kg12,500 units BD
140-154kg15,000 units am
12,500 units pm
155-169kg15,000 units BD

COVID-19 (DKA/HHS)

Experience is showing that those with diabetic patients with COVID-19 are more likely to develop DKA/HSS. However, treating them with the traditional large amount of fluid is detrimental to their chest, if they have Covid-19

Hence the following has been developed from the Guy & Thomas’ guidance – CLICK HERE

High Clinical Suspicion of Covid-19

  • Clinical: Fever ≥37.8°C plus any of; cough, short of breath, myalgia, headache, sore throat
  • CXR: consistent with Covid-19

Read more