A 30 year-old tourist from the Philippines was brought to the AED for abdominal distension.
On examination, his GCS was E3V4M5, with blood pressure 95/45 and pulse 70 per minute. There was external bruising over right hip. Before any further history could be taken, he suddenly developed vomiting and then aspiration. Crash endotracheal intubation was performed. A pelvic x-ray taken to screen for fracture did give clues for his condition.
Could you spot out the problem? What will be the next important step in managment?
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The AXR showed presence of multiple tubular opacities in rectum and descending colon. This was compatible with bodypacker.
Pupils were actually pin-pointed. After injection of Narcan 0.4mg IV, patient woke up and was so violent that heavy sedation was delivered in order to proceed to further management. The diagnosis of massive opiod overdose as a result of leaking of packs containing opiod was thus made.
One option of managing bodypackage of drug is accelerated removal by whole bowel irrigation (WBI) so as to prevent systemic absorption. However ileus is a contraindication of WBI, which will create intestinal obstruction and increase aspiration risk. For localized packs, endoscopic removal can be attempted, though the package can be easily broken down during manipulation, and only small part of intestine is approachable. For cases of massive ingestion, especially when the drugs are particularly hazardous eg.g cocaine, open method through laparotomy may be the only option left.
For this gentleman, colonoscopy during GA had removed most of the packages. Afterwards, the bowel movement returned, and thus WBI was employed to clear the remaining minority of drugs. He was extubated 2 days after staying in ICU, and was the discharged to custordial.