Version July 2025
| To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222, or the nearest international regional poison center. Contact information for poison centers around the world is available at the WHO website and in the UpToDate topic on regional poison control centers (society guideline links). |
| History |
| Inquire about type of drug, method of wrapping, number of packets |
| Physical exam |
| Assess for opioid toxicity |
| Depressed mental status, decreased respirations, pinpoint pupils, absent bowel sounds |
| Assess for cocaine toxicity |
| Agitation, hypertension, tachycardia, seizures, cardiac dysrhythmias |
| Assess for evidence of packets on physical examination (abdominal and rectal exams) |
| Assess for evidence of gastrointestinal obstruction or perforation (distension, tenderness) |
| Diagnosis |
| A plain abdominal radiograph is the best screening study |
| If suspicion is high but plain radiograph is negative, CT (or barium-enhanced abdominal radiography) should be performed |
| Urine toxicology testing lacks sensitivity as a screening test, but may identify packet content(s) |
| Treatment |
| Asymptomatic |
| Whole bowel irrigation (polyethylene glycol electrolyte lavage solution), 2 L/h plus promotility agent (erythromycin 500 mg IV, or metoclopramide 10 mg IV) |
| Gastrointestinal obstruction or perforation |
| Surgical decontamination |
| Evidence of opioid toxicity |
| Naloxone (high doses may be required: eg, 2 to 5 mg IV, may be given every 5 minutes until patient responsive) |
| Whole bowel irrigation, 2 L/h plus promotility agent |
| Evidence of cocaine toxicity |
| Benzodiazepines (eg, midazolam 1 to 2 mg IV, may be repeated); aggressive supportive care |
| Surgical decontamination |
| Endpoint of therapy |
| Abdominal CT (or contrast-enhanced plain radiography) to document clearance of all packets from the GI tract |
