Body packing and stuffing First detected case in Lithuania A 31 year old male was brought to the Department of Toxicology by customs officers after disembarking at the Vilnius International Airport suspecting of cocaine transport

Body packing and stuffing First detected case in Lithuania There were no any complaints and examination of patient didn’t show any pathology All blood tests were normal Patient refused endoscopy, but agree to contrast X- ray investigation Foreign bodies were detected in the gastrointestinal tract by X-ray photography Toxicological analysis for narcotics of urine and blood were done

Body packing and stuffing First detected case in Lithuania Observation (blood pressure, heart frequency, temperature, neurological assessment every hour) Mild laxative in conjunction with sufficient beverages

Body packing and stuffing First detected case in Lithuania “double condom’’ sign Fill defects Cocaine package show well demarcated rectangular shape high density shadows surrounded by gas halo ”double condom’’ sign on plain film

Body packing and stuffing First detected case in Lithuania 39 packets were excreted on the first day, 10 – on the second day, 3 – at the third day X-ray 3 days later revealed foreign bodies in the gastrointestinal tract (“double condom’’ sign) Because of customs officers demand the patient was transferred to the Hospital of Prison, despite staff objection. 62 cocaine packets were excreted during the next 3 days

Body packing and stuffing First detected case in Lithuania Forensic analysis Condoms were filled with 3-8 g of cocaine each 114 packages, weight 438,63 g,purity – 57% 2 of cocaine packets were slightly injured Blood sample – no answer, urine analysis – “possibility of cocaine metabolites”

Body packing and stuffing First detected case in Lithuania Our mistakes Offer of gastroscopy No express test (urine or blood) Removing from ICU settings to the Hospital of Prison without any emergency support, according to the patient’s claim and officers demand

Body packing and stuffing Management In no way endoscopic removal of the package should be attempted. The patient in whom only one packet fails to pass the pylorus may be the exception Conservative management during spontaneous evacuation of the containers is the first choice approach to the body-packing Surgery is indicated for patients with acute cocaine poisoning or gastrointestinal obstruction or perforation Observation till the last package removes is obligatory Although successful endoscopic removal of packets from the stomach has been reported, the risk of packet rupture during the procedure has led others to caution against it. Packets that are accessible to the endoscopist most likely represent only a fraction of the gastrointestinal burden, and the risk of rupture inherent in removing the packets usually outweighs the benefit. The patient in whom only one packet fails to pass the pylorus may be the exception; endoscopy in such a patient may be a reasonable alternative to surgery. Although heroin packets can be removed endoscopically in an intensive care unit in which naloxone is available, cocaine packets should be removed only in the operating room, with a surgical team prepared to intervene in the event of packet rupture. Unless the patient is being prepared for immediate surgery, gastrointestinal decontamination should be attempted. Activated charcoal reduces the lethality of oral cocaine, and 1 g per kilogram of body weight (up to 50 g) should be administered by mouth every four hours for several doses. Whole-bowel irrigation with a polyethylene glycol–electrolyte lavage solution results in a relatively gentle evacuation of the gastrointestinal tract and is safe for use in body packers. We administer a polyethylene glycol–electrolyte lavage solution at a rate of 2 liters per hour in adults — a rate that frequently requires the use of a nasogastric tube. Whole-bowel irrigation should be continued until complete clearance of the gastrointestinal tract is documented. The use of oil-based laxatives, although occasionally recommended, should be avoided because they reduce the tensile strength and "burst" volume of latex products. A massive gastrointestinal release of cocaine has been reported after the administration of oil-based laxatives.

Amphetamine Neurochemical actions Dose-related increase in release of norepinephrine, dopamine and serotonin: low dose: preferential action on NE release moderate dose: NE and DA release high dose: NE, DA and serotonin release Blockade of reuptake of NE, DA and serotonin Inhibition of MAO

Amphetamine Symptoms Agitation to psychosis Halucinations Mydriasis Tachycardia Hypertension Mild hypertermia Seizures Coma

Amphetamine Treatment No antidotes CPR GI decontamination gastric lavage, activated charcoal Benzodiazepines Severe hypertension phentolamin, nitropruside External cooling SVT Ca antagonists VT lidocaine No β-blockers

“Ecstasy” (MDMA): a hallucinogenic amphetamine Combination of psychostimulant effects with stronger hallucinogenic effects (serotonin component) Common acute adverse effects: muscle tension and bruxism Hyperthermia Increase HR and BP Acne-like rash

Cannabinoids Symptoms http://drugabuse.gov

Cannabinoids Symptoms Impairment of cognitive function Disorientation, talkativness Anxiety to panic Headache “Exploding chest” Sedation Ataxia Tremor Dry mouth Tachycardia Injected conjunctive

Cannabinoids Treatment Benzodiazepines Symptomic treatment Psychoterapy

LSD Symptoms Anxiety, agitation Hallucinations Moist and pale skin (Lysergic Acid Diethylamine) Anxiety, agitation Hallucinations Moist and pale skin Mild hypertension Tachycardia Hypertermia

LSD Treatment Benzodiazepines (Lysergic Acid Diethylamine) Benzodiazepines In severe cases – the same as amphetamines

Gamma-hydroxybutyric acid Symptoms CNS depression (GCS of 3 is not uncommon) Extreme combativeness and agitation Bradycardia Decreased systemic vascular resistance, hypotension Profound respiratory depression. GHB is found naturally in the CNS, with the highest concentrations in the basal ganglia It binds to GABA-B receptors in the brain, inhibits noradrenaline release in the hypothalamus, and mediates the release of an opiatelike substance in the striatum. It produces a biphasic dopamine response, increasing release at high doses and inhibiting release at lower doses.

Gamma-hydroxybutyric acid Treatment Airway protection and aspiration precautions Use atropine to treat symptomatic bradycardia that is unresponsive to stimulation

Solvents Symptoms Agitation, joy Vertigo, coordination damamge Sneeze, hypersalivation CNS depression, delusions Sense of invulnerability Respiratory depression Tachycardia Seizures, coma

Solvents Treatment Oxygen CPR (if needed) Benzodiazepines Symptomic treatment

Milestones in treatment of drug overdose Naloxone Benzodiazepines Life support measures