1. 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

2. 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

3. 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

4. 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

5. 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

6. 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”

7. 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

8. 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.

9. 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

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

11. 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

12. “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

13. Cannabinoids Symptoms

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

15. Cannabinoids Treatment
Benzodiazepines
Symptomic treatment
Psychoterapy

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

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

18. 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.

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

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

21. Solvents Treatment Oxygen CPR (if needed) Benzodiazepines
Symptomic treatment

22. Milestones in treatment of drug overdose
Naloxone
Benzodiazepines
Life support measures