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 – 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

2WW – Suspected Cancer

Some patients present to ED with symptoms or investigations suspicious an undiagnosed cancer, but don’t require emergency admission. To reduce the barriers to care the trust has implemented a referral route for ED.

Emergency Department MDT referral request – HERE

Once completed the PPC team will review the request and feed them into either “Fast-Track Clinics” if further workup required or MDT’s if fits those pathways.

This should allow our patients quick access to appropriate clinics, without the inherent delays and wasted clinical time of asking the patient to attend their GP. BMA/NHSe

Lower Back Pain: Red & Yellow Flags

Each year 1:15 of the adult population will seek medical help for Lower Back Pain, that is 2.6 million patients in the UK. Most Lower Back Pain is not serious and will revolve within 8 weeks, with analgesia and self physio.

However, this is not the case for some. This may be due to serious underlying pathology ‘RED Flags‘, or psychological factors that indicate chronicity ‘Yellow Flags‘.

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Hyperkalaemia

Remember: is it a haemolysed blood sample? (you can do an iSTAT)

Severity

  • Mild: 5.5-5.9mmol/l – No urgent action required (Dietary & Medication modification & GP F/U)
  • Moderate: 6.0-6.4mmol/l – Follow treatment guide (maybe suitable for discharge)
  • Severe: ≥6.5mmol/l OR ECG changes – Follow treatment guide, must admit

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Nitrous Oxide Induced Neurotoxicity

Nitrous Oxide  has been used clinically and recreationally since its discovery in 1772. Since then Nitrous Oxide induced neurotoxicity have been reported, and has been shown to be dose depaendant. With infrequent users unlikely to be at risk of neurotoxicity, while heavier and habitual used at risk of serious neurological conserquences.

With the increase in recreation use of “Whippits” we need to remember to take a detailed recreation drug history when seeing patients presenting to ED with neurological symptoms. As Nitrous Oxide induced neurotoxicity is treatable.

Presentations

Nitrous Oxide induced neurotoxicity can present as either spinal cord demyelination , peripheral neuropathy or a a combination of the two.

  • Demyelination of the dorsal columns of spinal cord 
    • Typically onset is subacute  (i.e. weeks), but acute onset has been reported in the literature
    • Typically symmetrical but can be unilateral
    • Signs
      • Pyramidal weakness – weak upper limb extensors, and lower limb flexors
      • Dorsal Column Sensory loss – Vibration, Proprioception, Fine touch
      • Sensory Ataxia – Incoordination due to loss of proprioception and weakness
    • Level – Most frequently cervical 4-6 levels, but can affect any.
  • Peripheral Neuropathy
    • Typically Symmetrical (but not always)
    • Sensory loss (often painful)
    • Distal Weakness
  • Optic Neuropathy  – has been reported and may present with visual disturbance.

Pathophysiology

Nitrous Oxide usage can render vitamin B12 inactive, which in-turn disrupts myelination, causing the demyelination of nerves.

Differentials

  • Deficiencies: B12, Folate, copper, zinc
  • Inflammatory: Guillian-Barre syndrome, MS, Neurosarcoidosis
  • Infection: HIV, Syphilis
  • Cancer
  • Vascular: Spinal cord ischaemia, vasculitis

Tests

  • Vitamin B12 level (often in normal range)
  • Homocysteine and Methylmalonic Acid Level (not available in ED)
  • MRI – contrast enhanced

Treatment

Start before Tests are back (i.e. on clinical suspicion)

  • IM Vitamine B12 1mg OD
  • PO Folic Acid 5mg OD

Follow-up

  • Discuss admission with Medical team as potential for SDEC management
  • Treat until clinical improvement(King’s Team noted the following)
    • Sometimes treat for 5-7days only
    • Often switch to alternate days IM Bit B12
    • Can teach to self administer
  • Further Testing
    • Homocysteine and Methylmalonic Acid levels – often improve quickly
    • MRI often lags clinical improvement endnote necessary to repeat
  • Majority Improve clinically – but futureabstinence is often challenging

 

References

Syncope – ESC 2018

  • Defintion:Transient Loss of Consciousness (TLOC) due to cerebral hypoperfusion, characterised by a rapid onset, short duration, and spontaneous complete recovery.
  • Common ED Complaint: 1.7% of all attendances
  • Difficult Diagnosis: less than 50% get a diagnosis in ED
  • Mortality & Serious Outcome: 0.8% mortality & 10.3% serious outcome @ 30 days

Ask 3 Questions!

  1. Is this Syncope?
  2. What is the underlying cause?
  3. What is the best Follow-Up for this patient?

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