A 22-Year-Old Who Fell Asleep on a Plane and Didn’t Wake Up

Anusuya Mokashi, MD; Dhana Rekha Selvaraj, MD, MBBS; Chandrasekar Palaniswamy, MD; Ali Nawaz Khan, FRCS, FRCP, FRCR; Prabhakar Rajiah, MD, MBBS, FRCR


May 21, 2020

For intoxication cases, initial management includes careful attention to the airway, breathing, and circulation (ABCs) and adequate resuscitation measures. Further management is based on the nature of the drug and toxidrome. Opioid poisoning is treated with a continuous infusion of naloxone. High doses may be necessary because large doses of drug may be released upon gastrointestinal rupture of the packets. Acute lung injury caused by opioid poisoning is treated with supplemental oxygen or intubation as needed.[2]

For cocaine poisoning, treatment should be initiated with high doses of benzodiazepines followed by intensive care management.[5] Ventricular arrhythmia should be managed with lidocaine and hypertonic sodium bicarbonate, and cocaine-induced hypertension should be treated with intravenous sodium nitroprusside or phentolamine.[2] In cases of leaking cocaine packets, immediate surgical removal is indicated because no specific antidote is available for cocaine overdose.[2]

Management of amphetamine poisoning is similar to that of cocaine poisoning, including prompt surgical removal of leaking packets.[2]Marijuana and hashish intoxication is managed with supportive treatment.[2]

In the case of bowel obstruction, activated charcoal can be given for cocaine packers at a dose of 1 g per kg of body weight (up to 50 g) every 4 hours for several doses. Oil-based laxatives should be avoided; however, whole-bowel irrigation with polyethylene glycol electrolyte lavage solution can be attempted to aid gentle passage of the packets.[2] Ipecac syrup, enemas, and cathartics carry a possibility of packet rupture and must not be used.[3] Endoscopic retrieval of packets also entails risk for rupture; therefore, this method is not usually recommended unless carried out in an ICU or operating room.[2,3] Imaging is to be repeated until three packet-negative stools are obtained or according to the count given by the packer to confirm that no packet is left behind.

Prompt surgical management is indicated for packers who present with complications of intestinal obstruction or perforation.[2] Enterotomy incisions are made as required, and the intestinal contents are milked toward the incisions or the anus.[2] Postoperative imaging (CT or barium study) should be done to ensure the complete removal of packets.[2]

In this case, the patient was administered a naloxone drip and was prepared for surgery. Evidence of packet rupture was found, and the packets were successfully removed. The patient survived the surgery and recovered well.

Cases of body packing have been increasing recently because strict border security procedures have made conventional drug smuggling difficult.[6] Physicians and radiologists should therefore be aware of this potentially fatal form of drug smuggling, its various presentations, and the relevant imaging findings in order to make a prompt diagnosis and begin the appropriate management.


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