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Bretler U, Shimron S, Bretler S, Yizhakov Y. Characterization and forensic identification of a novel cocaine charcoal smuggling matrix. Forensic Sci Int 2021; 330:111104. [PMID: 34826763 DOI: 10.1016/j.forsciint.2021.111104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/06/2021] [Accepted: 11/09/2021] [Indexed: 11/04/2022]
Abstract
Every year new and sophisticated drug-smuggling methods are encountered by law enforcement agencies all over the globe. A seized cross-border smuggling attempt was found to contain charcoal. This unexpected smuggling cargo raised doubts as to the real content of the material. Initial testing indicated that the black charcoal-like material contained cocaine. The material was forensically tested for cocaine presence and quantitatively analyzed for cocaine concentration. Initial testing with an illicit substance identification field kit and FTIR revealed that some of the material contained cocaine whereas other pieces were completely free of cocaine. Cocaine-containing material was quantitatively measured and was found to consist of over 50% cocaine. In addition, the morphology and element composition of the suspected matrix were analyzed by SEM and EDX. The results pointed to some structural and composition differences between material loaded with cocaine and charcoal free of the drug. One of the most significant and surprising differences in the element composition measurements was the finding of iron in the cocaine-containing material. Moreover, thermogravimetric analysis was performed on the samples to support the material composition analyses. Although the exhibits did not display a homogenous presence and concentration of cocaine, the porous morphological structure and the high cocaine concentration in some of the samples reveal that the carbon-rich matrix has a potential for high capacity drug uptake. The iron accompanying the cocaine is probably a left over product of the cocaine masking process.
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Affiliation(s)
- Uriel Bretler
- Division of Identification and Forensic Sciences (DIFS) Israel police HQ, Israel
| | - Simcha Shimron
- Division of Identification and Forensic Sciences (DIFS) Israel police HQ, Israel.
| | - Sharon Bretler
- Bar-Ilan Institute of Nanotechnology & Advanced Materials (BINA), Israel
| | - Yafit Yizhakov
- Division of Identification and Forensic Sciences (DIFS) Israel police HQ, Israel
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Cha MH, Sandooja R, Khalid S, Lao N, Lim J, Razik R. Complication rates in emergent endoscopy for foreign bodies under different sedation modalities: A large single-center retrospective review. World J Gastrointest Endosc 2021; 13:45-55. [PMID: 33623639 PMCID: PMC7890405 DOI: 10.4253/wjge.v13.i2.45] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 12/31/2020] [Accepted: 01/22/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Foreign object ingestion (FOI) and food bolus impaction (FBI) are common causes of emergent endoscopic intervention. The choice of sedation used is often dictated by physician experience. Many endoscopists frequently prefer to use monitored anesthesia care (MAC) and general anesthesia (GA) as opposed to conscious sedation (CS) due to the concern for inadequate airway protection. However, there is insufficient data examining the safety of different sedation modalities in emergent endoscopic management of FOI and FBI.
AIM To investigate the complication rates of emergent endoscopic extraction performed under different sedation modalities.
METHODS We conducted a retrospective chart review of patients presenting with acute FBI and FOI between 2010 and 2018 in two hospitals. A standardized questionnaire was utilized to collect data on demographics, endoscopic details, sedation practices, hospital stay and adverse events. Complications recognized during and within 24 h of the procedure were considered early, whereas patients presenting with a procedure-related adverse event within two weeks of the index event were considered delayed complications. Complication rates of patients who underwent emergent endoscopic retrieval were compared based on sedation types, namely CS, MAC and GA. Chi-square analysis and multiple logistic regression were used to compare complication rate based on sedation type.
RESULTS Among the 929 procedures analyzed, 353 procedures (38.0%) were performed under CS, 278 procedures (29.9%) under MAC and the rest (32.1%) under GA. The median age of the subjects was 52 years old, with 57.4% being male. The majority of the procedures (64.3%) were FBI with the rest being FOI (35.7%). A total of 132 subjects (14.2%) had chronic comorbidities while 29.0% had psychiatric disorders. The most commonly observed early complications were mucosal laceration (3.8%) and bleeding (2.6%). The most common delayed complication was aspiration pneumonia (1.8%). A total of 20 patients (5.6%) could not adequately be sedated with CS and had to be converted to MAC or GA. Patient sedated with MAC and GA were more likely to require hospitalization, P < 0.0001. Analysis revealed no statistically significant difference in the complication rate between patients sedated under CS (14.7%), MAC (14.7%) and GA (19.5%), P = 0.19.
CONCLUSION For patients who present with FOI or FBI and undergo emergent endoscopic treatment, there is no significant difference in adverse event rates between CS, MAC and GA.
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Affiliation(s)
- Ming-Han Cha
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH 44307, United States
| | - Rashi Sandooja
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH 44307, United States
| | - Saher Khalid
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH 44307, United States
| | - Nicole Lao
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH 44307, United States
| | - Joseph Lim
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH 44307, United States
| | - Roshan Razik
- Department of Gastroenterology, Cleveland Clinic Akron General, Akron, OH 44307, United States
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Parikh MP, Garg R, Gupta N, Sarvepalli S, Singhal A, Lopez R, Thota PN, Sanaka MR. National trends in healthcare outcomes and utilization of endoscopic and surgical interventions in patients hospitalized with esophageal foreign body and food impaction. Dis Esophagus 2020; 33:doaa018. [PMID: 32440674 DOI: 10.1093/dote/doaa018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/22/2020] [Indexed: 12/11/2022]
Abstract
The incidence and number of emergency room visits for esophageal foreign body and food impaction (EFB) are on the rise. However, its impact on the rate of inpatient admissions, utilization of endoscopic and surgical interventions, and healthcare outcomes is poorly understood. We conducted a study to analyze these outcomes using the national inpatient sample (NIS) database. Data on all adult patients (≥18 years) admitted with EFB was extracted from the NIS database from 1998 to 2013. The temporal trends in discharge rates as well as in length of stay (LOS), hospital charges, and in-hospital mortality rates were assessed by linear and polynomial regression. Average age, gender, and race of inpatients with EFB were not significantly different between 1998 and 2013. The rate of EFB admissions increased significantly from 1998 to 2005 followed by a decline thereafter (p = 0.01). LOS and hospital charges significantly increased by 0.02 days/year (p = 0.015) and $1,547/year (p < 0.001), respectively. There was a trend towards less utilization of overall esophagogastroduodenoscopy (EGD) over the last decade with significant lower use of EGD within 24 hours in 2013 as compared to 1998 (p = 0.026). The rates of surgical intervention and inpatient mortality did not change significantly over the study period. The rate of inpatient admissions for EFB is on the decline in recent years, suggesting the modern-day practice of cost-effective medicine. Hospitalization costs for EFB have increased, whereas rates of surgical intervention and inpatient mortality have not changed significantly over the study period.
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Affiliation(s)
- Malav P Parikh
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, USA
| | - Rajat Garg
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, USA
| | - Niyati Gupta
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, USA
| | - Shashank Sarvepalli
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, USA
| | - Akhil Singhal
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, USA
| | - Rocio Lopez
- Department of Biostatistics and Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, USA
| | - Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, USA
| | - Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, USA
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Fung BM, Sweetser S, Wong Kee Song LM, Tabibian JH. Foreign object ingestion and esophageal food impaction: An update and review on endoscopic management. World J Gastrointest Endosc 2019; 11:174-192. [PMID: 30918584 PMCID: PMC6425280 DOI: 10.4253/wjge.v11.i3.174] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 03/08/2019] [Accepted: 03/11/2019] [Indexed: 02/06/2023] Open
Abstract
Foreign body ingestion encompasses both foreign object ingestion (FOI) and esophageal food impaction (EFI) and represents a common and clinically significant scenario among patients of all ages. The immediate risk to the patient ranges from negligible to life-threatening, depending on the ingested substance, its location, patient fitness, and time to appropriate therapy. This article reviews the FOI and EFI literature and highlights important considerations and implications for pediatric and adult patients as well as their providers. Where published literature is insufficient to provide evidence-based guidance, expert opinion is included to supplement the content of this comprehensive review.
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Affiliation(s)
- Brian M Fung
- UCLA-Olive View Internal Medicine Residency Program, Sylmar, CA 91342, United States
| | - Seth Sweetser
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - Louis M Wong Kee Song
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - James H Tabibian
- Division of Gastroenterology, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
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Schmit G, Abdallah FB, Vanhaebost J, P. H. Prise en charge des body-packers. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
>Aujourd’hui, le body-packing ou transport in corpore de substances illicites est le mode de transport de drogues le plus répandu en Europe. Il porte essentiellement sur la cocaïne et l’héroïne, bien que toute autre substance puisse être concernée dans une moindre mesure. Les passeurs (« mules ») sont identifiés par les services de police et de douane sur la base de plusieurs indices permettant de les suspecter, comme l’origine des vols long-courriers, l’abstinence alimentaire, etc. La sensibilité du dépistage urinaire et le diagnostic reposent essentiellement sur l’imagerie abdominale, de préférence l’examen tomodensitométrique lorsqu’il est disponible. Les passeurs sont ensuite placés sous surveillance médicale. Celle-ci n’est pas standardisée, mais devrait durer au moins six heures, avec une attention particulière aux paramètres hémodynamiques et neurologiques. Le risque de rupture des paquets est principalement lié à la qualité de l’emballage. Le traitement est essentiellement conservateur. Les complications restent rares, et le recours à la chirurgie s’avère nécessaire en cas de signes d’intoxication et/ou d’occlusion digestive.
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Watson CJ, Thomson HJ, Johnston PS. Body-Packing with Amphetamines – an Indication for Surgery. J R Soc Med 2018; 84:311-2. [PMID: 2041016 PMCID: PMC1293238 DOI: 10.1177/014107689108400524] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- C J Watson
- Department of Surgery, Addenbrookes Hospital, Cambridge
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Pinto A, Reginelli A, Pinto F, Sica G, Scaglione M, Berger FH, Romano L, Brunese L. Radiological and practical aspects of body packing. Br J Radiol 2014; 87:20130500. [PMID: 24472727 DOI: 10.1259/bjr.20130500] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Body packing represents the concealment of illegal substances in a person's body with the aim of smuggling. "Body packers" either swallow drug-filled packets or introduce drug-filled packets into their bodies rectally or vaginally with the purpose of concealing them. The three main smuggled drugs are cocaine, heroin and cannabis products. Body packing represents a serious risk of acute narcotic toxicity from drug exposure, intestinal obstruction owing to pellet impaction and bowel perforation with consequent abdominal sepsis. A suspected body packer is generally admitted to hospital to perform imaging investigations and confirm the presence of drugs in his/her body. Radiological imaging methods are essential to diagnose body packing and to detect potential complications. Increasing sophistication of traffickers and improvements in packaging add to the detection difficulty. Radiologists should be aware of the appearance of drug packets in a range of imaging modalities. This article informs physicians about the challenging aspects of body packing, its background and medicolegal issues, what imaging methods can be used and what criteria are necessary to perform a correct diagnosis.
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Affiliation(s)
- A Pinto
- Department of Radiology, Cardarelli Hospital, Naples, Italy
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Kumral B, Büyük Y, Yeşiloğlu F, Özkan ÖL. A fatal case of heroin body packing in Turkey. Forensic Toxicol 2014. [DOI: 10.1007/s11419-013-0222-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Shadnia S, Faiaz-Noori MR, Pajoumand A, Talaie H, Khoshkar A, Vosough-Ghanbari S, Abdollahi M. A case report of opium body packer; review of the treatment protocols and mechanisms of poisoning. Toxicol Mech Methods 2012; 17:205-14. [PMID: 20020970 DOI: 10.1080/15376510600992574] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
ABSTRACT Body packers are people who illegally carry drugs, mostly cocaine as well as opium and/or heroin, concealed within their bodies. The packets are inserted in the mouth, rectum, or vagina in order to get across borders without being detected. In this presentation we report a case of an opium body packer and review the available scientific literature by focusing on mechanisms of toxicity and treatment approach. The patient was a 35-year-old man who had lethargy, respiratory depression, tachycardia, normal blood pressure, hyperthermia, and pinpoint pupils on presentation. No past medical history was obtained and the only positive history was his travel from Afghanistan 2 days earlier, which he had given to emergency personnel before arriving at our hospital. Complete blood cells and kidney and liver tests were all in normal range. In the emergency department, the patient was treated with oxygen, naloxone, and hypertonic glucose. One dose of activated charcoal (1 g/kg) was administered orally. After intravenous injection of naloxone (4 mg), the lethargy, respiratory depression, and miosis were resolved. The patient was admitted to the intensive care unit and 90 min after admission, the patient redeveloped respiratory distress and lost consciousness. He was intubated and mechanically ventilated due to the suspicious of body packing. Plain abdominal x-ray showed multiple packets throughout the gastrointestinal tract; 81 packets were removed by surgery and three of them were left due to leaking. After removing the packets, the patient was treated conservatively. He suffered a pulmonary infection (aspiration pneumonia) and he regained consciousness after 4 days. Upon recovery the patient was seen by a psychiatrist prior to going to prison. Surgery is recommended for body packers who have significant signs or symptoms.
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Affiliation(s)
- Shahin Shadnia
- Loghman-Hakim Hospital Poison Center, Faculty of Medicine, and Toxicological Research Center, Shaheed Beheshti University of Medical Sciences, Tehran, Iran
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Lee K, Koehn M, Rastegar RF, van Hoorn F, Roy E, Berger FH, Nicolaou S. Body packers: the ins and outs of imaging. Can Assoc Radiol J 2012; 63:318-22. [PMID: 22280790 DOI: 10.1016/j.carj.2011.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Revised: 06/14/2011] [Accepted: 06/23/2011] [Indexed: 01/08/2023] Open
Affiliation(s)
- Kristy Lee
- Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Body packers: a plea for conservative treatment. Langenbecks Arch Surg 2011; 397:125-30. [PMID: 21984212 PMCID: PMC3224221 DOI: 10.1007/s00423-011-0846-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 09/02/2011] [Indexed: 01/08/2023]
Abstract
Background The incidence of smuggling and transporting of illegal drugs by internal concealment, also known as body packing, is increasing in the Western world. The objective of this study was to determine the outcome of conservative and surgical approaches in body packers. Materials and methods Clinical data on body packers admitted to our hospital from January 2004 until December 2009 were collected. The protocol for body packers required surgery when packets were present in the stomach for >48 h. Outcomes of the conservative and surgical group were assessed and analyzed. Morbidity and mortality were assessed in body packers with drug packets present in the stomach for <48 h and in those with gastric packets for >48 h. Results During the study period, more body packers were treated conservatively. Mortality was 2% in all patients and was due to intoxication. There were no significant differences of mortality, hospital admission time, and ICU admission time in the compared groups with drug packets in the stomach for less or >48 h. In 24% (4/17) of the patients with bad package material, a ruptured drug packet was found during surgery. This resulted in death in only one patient. Conclusion Drug packets in the stomach for >48 h are not an indication for surgery. We recommend that surgery should only be performed in body packers with signs of intoxication or ileus and reserve conservative treatment for all other patients.
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Ikenberry SO, Jue TL, Anderson MA, Appalaneni V, Banerjee S, Ben-Menachem T, Decker GA, Fanelli RD, Fisher LR, Fukami N, Harrison ME, Jain R, Khan KM, Krinsky ML, Maple JT, Sharaf R, Strohmeyer L, Dominitz JA. Management of ingested foreign bodies and food impactions. Gastrointest Endosc 2011; 73:1085-91. [PMID: 21628009 DOI: 10.1016/j.gie.2010.11.010] [Citation(s) in RCA: 486] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 11/05/2010] [Indexed: 02/08/2023]
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Occupational hazard: Treating cocaine body packers in Caribbean countries. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2009; 20:377-80. [DOI: 10.1016/j.drugpo.2008.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Revised: 05/27/2008] [Accepted: 06/17/2008] [Indexed: 01/08/2023]
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Peake STC, Das S, Greene S, Dubrey SW. Cocaine ‘body packers’ and the clinical management of packet rupture. Br J Hosp Med (Lond) 2009; 70:110-1. [DOI: 10.12968/hmed.2009.70.2.38914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
| | - Saroj Das
- The Hillingdon Hospital, Uxbridge, Middlesex UB8 3NN
| | - Shaun Greene
- Clinical Toxicology, Guys and St Thomas' Poisons Unit, London and
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Abstract
BACKGROUND Internal concealment of illicit drugs during international drug traffic represents an important problem in developed countries. These drug traffickers are called "body packers." The aim of this study was to analyze retroprospectively the surgical indications and complications for cocaine body packers and to describe our systematic operative protocol. METHODS From January 1997 to December 2005, 1,181 cocaine body packers were admitted to our Medico-Judiciary Emergency Department. All patients had the same medical surveillance protocol. Nineteen patients required surgical procedure to remove drug packets. RESULTS Thirteen patients had obstruction or intestinal retention (68%). Suspicion of packet rupture or cocaine intoxication occurred in six patients (32%). Zero to three enterotomies were necessary during laparotomy. No deaths occurred. One pouch abscess required relaparotomy and one wound abscess was treated medically. The median hospital stay was 7 days (range: 5-30 days). CONCLUSIONS Few cocaine body packers required a laparotomy. Our systematic operative protocol allowed intestinal clearance and caused acceptable morbidity rate.
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Abstract
Smuggling of illicit drugs by concealing them within the human body (body packer) is a medical-legal issue that has increased in the last few decades. Physicians, especially those working in the emergency department, should be familiar with the diagnostic and therapeutic management -usually conservative management- of this type of patient and their possible complications. The present article reviews the general concepts and physiopathology associated with transport of packages in the digestive tract and describes the experience of a referral hospital with a protocol specifically designed for these patients.
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de Beer SA, Spiessens G, Mol W, Fa-Si-Oen PR. Surgery for body packing in the Caribbean: a retrospective study of 70 patients. World J Surg 2008; 32:281-5; discussion 286-7. [PMID: 18060451 DOI: 10.1007/s00268-007-9316-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Body packing is a way to deliver packages of drugs hidden in body cavities, across international borders. This may cause mechanical bowel obstruction and intoxication leading to emergency surgery. The objective of this retrospective study is to evaluate pre-, per- and postoperative characteristics of body packing and its complications and prognosis after surgery. METHODS Medical information was obtained from 70 patients diagnosed with Body Packer syndrome who underwent surgery for body packing in the period of July 2001-July 2005 at the St. Elisabeth hospital, Curaçao, the Netherlands Antilles. RESULTS Wound infection occurred in 32.9% and fascia dehiscence in 2.9%. Most procedures were enterotomies. One patient had a re-laparotomy for Hartmann's procedure because of an anastomotic leak and three other patients had a partial small bowel resection. The creation of a stoma was only needed in one patient. One patient died of postoperative DIC. In six patients packages were left behind, not requiring re-operation. CONCLUSIONS Bowel obstruction and symptoms of intoxication are clear indications for surgery in body packing patients. In our study there was a low mortality and stoma placement rate, we did find a remarkable high amount of wound infection but no evidence for a higher incidence of fascia dehiscence in comparison with elective gastrointestinal surgery. In surgery for bodypacking a mandatory postoperative x-ray is indicated. A prospective trial is needed to assess more information about possible predictive factors of postoperative complications and mortality after surgery for body packing.
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Affiliation(s)
- S A de Beer
- Rijnstate Hospital, Wagnerlaan 55, Arnhem, the Netherlands.
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Kelly J, Corrigan M, Cahill RA, Redmond HP. Contemporary management of drug-packers. World J Emerg Surg 2007; 2:9. [PMID: 17448234 PMCID: PMC1868019 DOI: 10.1186/1749-7922-2-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2006] [Accepted: 04/20/2007] [Indexed: 01/08/2023] Open
Abstract
Experience with management of drug-packers (mules) is variable among different centres. However, despite a recorded increase in drug trafficking in general, as yet, no unified, clear guidelines exist to guide the medical management of those who only occasionally encounter these individuals. We describe our recent experience with this growing problem and discuss the most salient points concerning the contemporary management of body packers. Our recent experience demonstrates that type IV packages may now be managed conservatively for the most part.
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Affiliation(s)
- J Kelly
- Department of Surgery, Cork University Hospital, Wilton, Cork, Ireland
| | - M Corrigan
- Department of Surgery, Cork University Hospital, Wilton, Cork, Ireland
| | - RA Cahill
- Department of Surgery, Cork University Hospital, Wilton, Cork, Ireland
| | - HP Redmond
- Department of Surgery, Cork University Hospital, Wilton, Cork, Ireland
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Abstract
BACKGROUND "Body packing" of illegal drugs has increased in the last decades, and with it our experience in treating these patients, yet no clear guidelines for surgical treatment are available. We examined the characteristics and outcomes of patients who required surgical intervention. STUDY DESIGN Charts of all patients who underwent surgery at our institution for ingested drug packets between January 1990 and January 2005 were reviewed. Patients were identified by a pre-existing list of names collected prospectively and by admission codes. Reviewed parameters included presentation, method of diagnosis, indication for surgery, procedure, and patient outcome. RESULTS Twenty-five patients were identified, for whom charts were available for review. Main indications for surgery were drug toxicity and small bowel obstruction. Most packets were retrieved using a combination of milking and multiple enterotomies. A high rate (40%) of postoperative wound infection was found. The incidence of wound infection correlated significantly with the number of enterotomies. CONCLUSION Surgical intervention for body packing remains the treatment for a minority of these patients. Patients should be placed in lithotomy to facilitate the exposure of the entire gastrointestinal tract, and to allow milking of the packets and their possible retrieval through the anus. The number of enterotomies should be minimized in order to reduce the risk of wound infection. If multiple enterotomies are used, the surgeon should consider leaving the wound open for delayed closure.
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Affiliation(s)
- Daniel Silverberg
- Department of Surgery, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA.
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de Prost N, Lefebvre A, Questel F, Roche N, Pourriat JL, Huchon G, Rabbat A. Prognosis of cocaine body-packers. Intensive Care Med 2005; 31:955-8. [PMID: 15909167 DOI: 10.1007/s00134-005-2660-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2004] [Accepted: 12/17/2004] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To study the prognosis and complications of cocaine body-packing (concealment of cocaine in the body for transportation between countries). DESIGN We retrospectively reviewed the files of all cocaine body-packers hospitalized during a 4-year period in a medico-judiciary emergency unit. Subjects included in the survey were identified from the hospital databases using ICD-10 codes. SETTING The Medico-Judiciary Emergency Unit of Hôtel-Dieu university hospital in Paris is a unique medical and surgical emergency unit receiving all patients in legal custody arrested at the two Paris international airports and suspected of body-packing. PATIENTS All the cases of cocaine body-packers (n=581) hospitalized between January 1999 and December 2002 were studied. They had been arrested at Paris airports while arriving from drug-producing countries. RESULTS The mean number of carried packets was 70.0+/-20.4 (range 18-150). The mean duration of hospitalization was 5.0+/-1.6 days (range 1-18). No complication occurred in 573 body-packers cases. Eight subjects developed a complication requiring admission to an intensive care unit: six acute cocaine intoxications due to packet rupture and two intestinal occlusions. No one died. Surgical treatment was necessary in six cases. CONCLUSIONS Good prognosis observed in these body-packers cases is due to the careful monitoring of asymptomatic patients, allowing early detection and treatment of complications. Surgical removal of the packets when complication occurs is warranted.
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Affiliation(s)
- Nicolas de Prost
- Respiratory and Intensive Care Unit, Hôtel-Dieu, 1 Place du Parvis de Notre-Dame, 75004, Paris, France
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Wittau M, Weber D, Reher B, Link KH, Henne-Bruns D, Siech M. [Emergent surgery for body packing - what happens to the drugs?]. Chirurg 2004; 75:436-441. [PMID: 15034671 DOI: 10.1007/s00104-004-0841-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Body packing is a well recognized method of drug trafficking by smuggling drug containers in the gastrointestinal tract. Medical professionals might get involved with body packers after presentation by law enforcement or in case of medical emergencies such as drug overdose or mechanical intestinal obstruction due to the containers within the gastrointestinal tract. Besides the medical aspects in treating these patients, physicians must be aware of all the different legal specifics in dealing with body packers. In case of medical emergencies, drug traffickers have the legal status of regular patients with respect to professional medical discretion. The question remains of what physicians should do with the drugs after surgical removal? Even though the body packer remains the legal owner of the drugs, physicians may not return the drugs, since that constitutes the criminal offence of dealing in narcotics. Returning the drugs to law enforcement authorities is also prohibited because of professional medical discretion. The only way out of this predicament is for physicians to destroy the drugs under the observation of witnesses.
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Affiliation(s)
- M Wittau
- Abt. Chirurgie I, Universitätsklinik der Universität Ulm
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23
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Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, Mallery JS, Raddawi HM, Vargo JJ, Waring JP, Fanelli RD, Wheeler-Harbough J. Guideline for the management of ingested foreign bodies. Gastrointest Endosc 2002; 55:802-6. [PMID: 12024131 DOI: 10.1016/s0016-5107(02)70407-0] [Citation(s) in RCA: 345] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
This is one of a series of statements discussing the utilization of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.
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Bulstrode N, Banks F, Shrotria S. The outcome of drug smuggling by 'body packers'--the British experience. Ann R Coll Surg Engl 2002; 84:35-8. [PMID: 11890624 PMCID: PMC2503744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Body packing or internal concealment used by drug dealers to smuggle illicit substances, puts the body packer at risk of both imprisonment and death. We report our experience over a 4 year period from January 1996 to December 1999 of suspects presenting to our hospital (the largest series in Europe). A total of 572 cases were assessed radiographically and 180 were shown to be carrying foreign bodies. The commonest reasons for admission were suspected overdose or gastrointestinal obstruction. Thirty-six cases were admitted, of whom 7 required surgical intervention. No deaths occurred. Of all people detained for smuggling by internal concealment into Britain during this period, 27% were seen in our hospital. These cases may present alone or escorted by Her Majesty's Customs and Excise personnel, and one must be aware of this possibility even when situated away from a port of entry.
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25
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Olmedo R, Nelson L, Chu J, Hoffman RS. Is surgical decontamination definitive treatment of "body-packers"? Am J Emerg Med 2001; 19:593-6. [PMID: 11699007 DOI: 10.1053/ajem.2001.21720] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The current recommendations for body-packers are based on packet content, the presence of drug toxicity, or of bowel obstruction. Asymptomatic patients are usually treated with activated charcoal and whole bowel irrigation (WBI). Surgical removal of packets is advocated in symptomatic cocaine body-packers and in those with bowel obstruction. Currently, surgery is regarded as definitive. However, we report 2 body-packers who show the limitations of this technique. These cases show the importance of confirming the absence of drug packets in the gastrointestinal (GI) tract as the definitive end-point in the treatment of body-packers.
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Affiliation(s)
- R Olmedo
- Division of Toxicology, Department of Emergency Medicine, Mount Sinai School of Medicine, The Mount Sinai Medical Center, The Mount Sinai Hospital, New York, NY 10029-6574, USA
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26
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27
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Affiliation(s)
- A L Jones
- National Poisons Information Service (London), Medical Toxicology Unit, Guy's and St Thomas's NHS Trust, London SE14 5ER.
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28
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Affiliation(s)
- N A Watson
- Department of Diagnostic Radiology, University of Manchester
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29
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Affiliation(s)
- A Krishnan
- King's College School of Medicine and Dentistry, King's College Hospital, London
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30
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Affiliation(s)
- L Visser
- The Hague Hospitals Central Pharmacy, Netherlands
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31
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Dizon MN, Matfin G. Abdominal pain in a healthy young man. Postgrad Med J 1998; 74:183-5. [PMID: 9640451 PMCID: PMC2360845 DOI: 10.1136/pgmj.74.869.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- M N Dizon
- Department of Internal Medicine, University of South Florida, College of Medicine, Tampa 33612, USA
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32
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Affiliation(s)
- H M al-Attia
- Department of Internal Medicine, Mafraq Hospital, Abu Dhabi, United Arab Emirates
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33
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Affiliation(s)
- J A Henry
- Medical Toxicology Unit, Guy's Hospital, London
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34
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Abstract
A fatality in a teenage drug courier who swallowed multiple packages of a controlled drug for concealment in the gastrointestinal tract is described. There were a couple of burst-open short cylindrical packages of cocaine and several with damaged external latex wrapping. A hazardous breakage or leakage has been considered unlikely with similar type of cocaine packages otherwise. The deceased succumbed to a remarkably high fatal postmortem blood cocaine concentration of 104 mg/l, having curiously survived the usual lethal range for cocaine toxicity. The phenomenon of postmortem release and redistribution of drugs and spontaneous biodegradation of cocaine which may confound the postmortem toxicology is briefly discussed. There is a comparable forensic problem in estimating the time of drug ingestion from the rate of gastric emptying or transit in the gut as a crude guide to deduce the time of death.
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Affiliation(s)
- F Patel
- Department of Forensic Medicine (University of London), UK
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35
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Abstract
This guideline is intended to aid the endoscopist in the management of adult patients with possible foreign object ingestion and/or food bolus impaction. A literature search was performed on the Medline using Medlars II, the National Library of Medicine's National Interactive Retrieval Service. This search generated 181 citations. References chosen for review were English-language citations from the gastroenterology, otolarygology, general surgical, and radiological literature. As little or no data exist from well-designed prospective trials, emphasis was given to results from large series, and reports from recognized experts. In preparing this guideline several drafts were distributed to the members of the ASGE Standards of Practice Committee, to the practice committees of the AGA, ACG, and SAGES, and to national experts on this subject for critical review. A final draft was then reviewed by the ASGE Governing Board. The final guideline reflects the input from this review process.
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36
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37
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Glass JM, Scott HJ. 'Surgical mules': the smuggling of drugs in the gastrointestinal tract. J R Soc Med 1995; 88:450-3. [PMID: 7562828 PMCID: PMC1295299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The presentation to surgical units of patients carrying illegal drugs in the gastrointestinal tract is a frequent occurrence at hospitals sited close to international airports. Drugs, usually heroin or cocaine, are wrapped in cellophane packets or condoms. The packages are intracorporeally concealed by being swallowed or passed into the rectum. The majority of drug traffickers carrying intracorporeal drug packages do not require any medical intervention. Recent reports have suggested that these patients are best treated expectantly avoiding any operative procedures. However, the quantity of drug in any one of the ingested packets is usually above the toxic dose and acute drug toxicity, as well as bowel obstruction, can result in fatalities. We report a series of five patients who presented over a period of 2 years to a hospital close to Heathrow International Airport, London. The presentation and treatment are reviewed and the management of such 'surgical mules' discussed. We have shown that conservative treatment is appropriate providing bowel obstruction or package perforation has not occurred.
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Affiliation(s)
- J M Glass
- Department of Surgery, Ashford Hospital, Middlesex, England, UK
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38
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Abstract
Drug smuggling by internal bodily concealment is a well-recognized international problem, particularly in view of the difficulty of its detection and the potential for large financial gains. This mode of transport can have serious medical complications, including drug intoxication--sometimes fatal--as well as intestinal obstruction by foreign bodies (FBs). We discuss a case of heroin 'bodypacking' (the ingestion of heroin filled condoms) with its resultant complications. The initial medical management and indications for surgery are discussed, and the relevant literature reviewed.
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Affiliation(s)
- P J Leo
- Mount Sinai School of Medicine Integrated Residency in Emergency Medicine, New York, USA
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39
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Abstract
This review article is intended to aid the clinician in the evaluation and management of older children and adult patients with possible foreign object ingestion and/or food bolus impaction. A literature search was performed in June 1993 on the Medline using Medlars II, the National Library of Medicine's National Interactive Retrieval Service. This search generated 181 citations. References chosen for review were English-language citations from the gastroenterology, otolaryngology, general surgical, and radiological literature. As little or no data exist from well-designed prospective trials, emphasis was given to results from large series. In preparing this manuscript several drafts were distributed to the members of the American Society for Gastrointestinal Endoscopy, Standards of Practice Committee, and to national experts on the subject for critical review.
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Affiliation(s)
- G G Ginsberg
- Hospital of the University of Pennsylvania, Gastroenterology Division, Philadelphia 19104, USA
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40
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Abstract
Intracorporeal drug smuggling, particularly of cocaine, is increasing. The so-called 'body packers' present a difficult clinical problem, particularly as no coherent management policy has been formulated. The various methods of diagnosis and the treatment options available are presented and discussed.
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Affiliation(s)
- N E Beck
- Department of Surgery, East Surrey Hospital, Redhill, UK
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41
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42
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Ginsberg GG, Lipman TO. Endoscopic diagnosis of thermal injury to the laryngopharynx after crack cocaine ingestion. Gastrointest Endosc 1993; 39:838-9. [PMID: 8293917 DOI: 10.1016/s0016-5107(93)70283-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- G G Ginsberg
- Department of Veterans' Affairs Medical Center/Georgetown University Medical Center, Washington, D.C. 20007
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43
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Affiliation(s)
- J Nicholls
- Department of Pathology, University of Hong Kong
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44
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Makosiej FJ, Hoffman RS, Howland MA, Goldfrank LR. An in vitro evaluation of cocaine hydrochloride adsorption by activated charcoal and desorption upon addition of polyethylene glycol electrolyte lavage solution. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1993; 31:381-95. [PMID: 8355315 DOI: 10.3109/15563659309000407] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Cocaine body-packers and body-stuffers have become a common medical problem. Significant morbidity and mortality result when cocaine is absorbed from the gastrointestinal tract due to cocaine package compromise. The clinical prevention of gastrointestinal absorption of cocaine includes oral activated charcoal and/or whole bowel irrigation with polyethylene glycol--electrolyte lavage solution. This in vitro study investigates the maximal adsorptive capacity of activated charcoal for cocaine at varying activated charcoal:cocaine ratios, at pH 1.2 and pH 7.0, and the effect of polyethylene glycol--electrolyte lavage solution upon this binding. The percent adsorption of cocaine to activated charcoal was significantly better at pH 7.0 for all ratios of activated charcoal:cocaine tested and the maximal adsorptive capacity was 29% greater at pH 7.0 (273 micrograms/mg) than at pH 1.2 (212 micrograms/mg) (p < 0.05). Addition of polyethylene glycol--electrolyte lavage solution to the cocaine-activated charcoal slurry caused significant desorption of cocaine from activated charcoal at all pHs and ratios tested (except the 1:1 ratio at pH 7.0) and was most pronounced at pH 1.2. The addition of polyethylene glycol--electrolyte lavage solution to activated charcoal prior to adding cocaine solution further decreased the adsorption of cocaine to activated charcoal. This difference was significant at both pHs and all ratios tested except the 1:1 ratio at pH 1.2. The maximal adsorptive capacity of activated charcoal for cocaine at pH 1.2 was reduced 75% by pretreatment with polyethylene glycol--electrolyte lavage solution from 212 to 54.2 micrograms/mg, while at pH 7.0 the maximal adsorptive capacity was reduced by 11%, from 273 to 243 micrograms/mg. Polyethylene glycol--electrolyte lavage solution significantly reduces the adsorption of cocaine to activated charcoal particularly if the two are combined at a low pH prior to the addition of cocaine. The in vitro effects suggest that activated charcoal mixed in water should be administered first, followed by the polyethylene glycol--electrolyte lavage solution.
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45
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Abstract
Fourteen body packers carrying 2-112 heroin packages are reported. Nine people swallowed the packets, and five inserted them rectally. The ingested packages were large and radio-opaque; they consisted of hard lumps of concentrated heroin usually covered with glove latex, white adhesive tape, and a toy balloon. There were two complications in the 14 patients. One patient developed a bowel obstruction; at laparotomy 8 packages were found in the stomach and 27 at the ileo-cecal valve. Another patient, with heroin wrapped only with black electrician's tape and no latex inner or outer wrappings, developed heroin intoxication, noncardiogenic pulmonary edema, and a bowel obstruction. Eighteen packages were surgically removed from his stomach and 26 from his bowel. We recommend bisacodyl suppositories, activated charcoal mixed with a 3% sodium sulfate cathartic, and phosphosoda enemas for package removal; close observation for heroin toxicity or bowel obstruction; and surgical intervention for continuing toxicity, retention of packages in the stomach, or bowel obstruction.
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Affiliation(s)
- M J Utecht
- University of Southern California School of Medicine, Los Angeles
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46
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Abstract
Drug smuggling by intra-abdominal concealment is now a world-wide problem. This paper describes the establishment of a plain radiography service to assist customs officers of Manchester International Airport (MIA) in their work. Over a 2 1/2 year period, 158 suspected 'body packers' were radiographed, resulting in nine positive detections. The existence of the service has resulted in the apparent abandonment of MIA as a port of entry by an organized group of cocaine smugglers. Practical and ethical problems are described. This service is felt to be essential by the customs officers and a valuable service to society by the radiologists and hospital authorities concerned.
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Affiliation(s)
- A W Horrocks
- Department of Radiology, Wythenshawe Hospital, Manchester
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47
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Marc B, Baud FJ, Maison-Blanche P, Leporc P, Garnier M, Gherardi R. Cardiac monitoring during medical management of cocaine body packers. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1992; 30:387-97. [PMID: 1512812 DOI: 10.3109/15563659209021554] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The cardiac risk of cocaine body packing was studied by means of continuous ECG monitoring in 13 cocaine body-packers during spontaneous elimination. The packages were all well manufactured bundles (McCarron type 2) not susceptible to spontaneous breakage. At the beginning of the Holter study, packages were still present in the bowel of twelve patients (range: 2 to 196). The mean time of Holter recording was 46 h (range 16 h to 75 h). Ten patients eliminated all their packages during the time of Holter recording. No ECG modifications were recorded for all of the patients in regard to usually admitted standard requirements of the American Heart Association. While initial cardiac frequencies were within the normal range, a significant decrease of pulse rates was associated with the elimination of bundles. We conclude that the McCarron type 2 cocaine body-packers are not in impending danger of cardiac acute events allowing a non-surgical management of these individuals.
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Affiliation(s)
- B Marc
- Hôpital Fernand Widal, Paris, France
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48
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49
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Hoffman RS, Smilkstein MJ, Goldfrank LR. Whole bowel irrigation and the cocaine body-packer: a new approach to a common problem. Am J Emerg Med 1990; 8:523-7. [PMID: 2222597 DOI: 10.1016/0735-6757(90)90155-s] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Gastrointestinal drug smuggling is a common problem in many major cities. Though the majority of cases never require medical attention, the "body-packer" frequently presents with life-threatening symptoms of intoxication, including seizures and cardiorespiratory collapse, as well as mechanical obstruction from the ingested drug packets. The risk to asymptomatic smugglers may vary with packaging materials, and remains unknown. Lack of controlled studies, and variations in packaging materials and clinical outcomes have prevented formulation of a consistent management strategy. Current recommendations for asymptomatic body-packers vary from immediate surgical removal, to use of laxatives, to observation. The authors present the first reported case of an asymptomatic cocaine body-packer treated with whole bowel irrigation with polyethylene glycol electrolyte lavage solution. This strategy was safe, well tolerated, resulted in the rapid elimination of drug packets from the gastrointestinal tract, and facilitated assessment by contrast radiography. The potential benefits and limitations for the use of whole bowel irrigation in this difficult problem are discussed.
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Affiliation(s)
- R S Hoffman
- New York City Poison Control Center, NY 10016
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50
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Dawling S, Essex EG, Ward N, Widdop B. Gas chromatographic measurement of cocaine in serum, plasma and whole blood. Ann Clin Biochem 1990; 27 ( Pt 5):478-81. [PMID: 2281928 DOI: 10.1177/000456329002700510] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A gas chromatographic method is presented to measure cocaine in serum, plasma or blood. To reduce the in-vitro chemical and enzymic hydrolysis of cocaine, samples should be collected into fluoride oxalate tubes, frozen immediately and stored at -20 degrees C until analysis. Extractions are carried out in disposable glass tubes immersed in an ice-bath. The method uses a single step extraction from a mildly basic solution into n-butyl acetate containing maprotiline internal standard. A portion of the upper organic layer is chromatographed for 5 min isothermally on a packed column (3% SP2250) with nitrogen-phosphorus detection. The coefficient of variation (CV) of the assay is below 6% at 0.1 mg/L and the limit of accurate measurement is 0.02 mg/L. A case of acute cocaine intoxication is described to illustrate the application of the method.
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Affiliation(s)
- S Dawling
- Poisons Unit, Guy's Hopital, London, UK
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