AEM Early Access 09: The Hack's Impairment Index (HII) Score

Welcome to the ninth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners. This one is a mid-month bonus!

Find this podcast series on iTunes here.

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM


Performance of the Hack’s Impairment Index Score: A Novel Tool to Assess Impairment from Alcohol in Emergency Department Patients Jason B. Hack, MD, Eric J. Goldlust, MD, Dennis Ferrante and Brian J. Zink, MD

(click on title for full text; open access through January 5, 2018)     

listen now: interview with lead author Dr. Jason Hack


Jason Hack, MD, FACEP, FACMT
Director,  Division of Medical Toxicology. Brown University
Professor, Department of Emergency Medicine
Warren Alpert Medical School, 
Brown University


Background: Over 35 million alcohol-impaired (AI) patients are cared for in emergency departments (EDs) annually. Emergency physicians are charged with ensuring AI patients’ safety by identifying resolution of alcohol induced impairment. The most common standard evaluation is an extemporized clinical examination, as ethanol levels are not reliable or predictive of clinical symptoms. There is no standard assessment of ED AI patients.

Objective: The objective was to evaluate a novel standardized ED assessment of alcohol impairment, Hack’s Impairment Index (HII score), in a busy urban ED.

Methods: A retrospective chart review was performed for all AI patients seen in our busy urban ED over 24 months. Trained nurses evaluated AI patients with both “usual” and HII score every 2 hours. Patients were stratified by frequency of visits for AI during this time: high (≥ 6), medium (2–5), and low (1). Within each category, comparisons were made between HII scores, measured ethanol levels, and usual nursing assessment of AI. Changes in HII scores over time were also evaluated. Results: A total of 8,074 visits from 3,219 unique patients were eligible for study, including 7,973 (98.7%) with ethanol levels, 5,061 (62.7%) with complete HII scores, and 3,646 (45.2%) with health care provider assessments. Correlations between HII scores and ethanol levels were poor (Pearson’s R2 = 0.09, 0.09, and 0.17 for high-, medium-, and low-frequency strata). HII scores were excellent at discriminating nursing assessment of AI, while ethanol levels were less effective. Omitting extrema, HII scores fell consistently an average 0.062 points per hour, throughout patients’ visits.

Conclusions: The HII score applied a quantitative, objective assessment of alcohol impairment. HII scores were superior to ethanol levels as an objective clinical measure of impairment. The HII declines in a reasonably predictable manner over time, with serial evaluations corresponding well with health care provider evaluations.


CORRECTIVE NOTE: Dr. Hack would like to note a correction in the podcast audio, in which he states the HII sections are scored 'up to five'; rather, there are five sections/tasks, with a score of zero to four in each. 


Further reading:

1.    Hack JB, Goldlust D, Ferrante D, Zink B.  The HII Score – A Novel Tool to Assess Impairment from Alcohol in Emergency Department Patients. Acad Emerg Med. 2017 Oct; 24(10):1193-1203.

2.   Hack JB, Goldlust EJ, Gibbs F, Zink B. The H-Impairment Index (HII): a standardized assessment of alcohol induced impairment in the emergency department. Am J Drug Alcohol Abuse 2014;40:111–7.

3.   Benoit JL, Hart KW, Soliman AA, et al. Developing a standardized measurement of alcohol intoxication. Am J Emerg Med 2017;35:725–30.

4.   Todd K, Berk WA, Welch RD, et al. Prospective analysis of mental status progression in ethanol-intoxicated patients. Am J Emerg Med 1992;10:271– 3. 5.    

5.   Galbraith S. Misdiagnosis and delayed diagnosis in traumatic intracranial haematoma. Br Med J 1976;1:1438– 9.  

Pusher, Packer, or Stuffer? A Case of Pediatric Drug Use

The Case

An otherwise healthy 15-year-old male presents to the ED in the custody of police for drug ingestion. The patient reported intentional ingestion of a plastic bag of heroin laced with fentanyl 45 minutes prior to arrival to avoid arrest by police.

The patient denies headache, palpitations, nausea, emesis, diarrhea, or abdominal pain. On exam, the patient is afebrile and vital signs are within normal limits. He is in no distress and is awake, alert, and oriented to person, place, and day. Pupils are 3 mm and respond equally to light. He is breathing comfortably and has no abdominal pain on palpation. His skin is warm and dry.

What is the term used to describe this patient’s ingestion?

  1. Body Packing
  2. Body Stuffing
  3. Body Pushing
  4. Body Filling
Body Stuffer


Concealment of illicit drugs in the body can be divided into “body packing” and “body stuffing.” (1) 

Body packing is the prearranged and generally well-coordinated ingestion for the purposes of drug trafficking.

On the other hand, body stuffing is the hurried swallowing of drugs to avoid immediate arrest.

Body packers will carry approximately 1kg (2.2 lbs) of total drug, divided into 50 to 100 packets. (2) Each packet containing enough drug to be lethal. Meanwhile, body stuffers ingest smaller amounts, which are typically for individual use. The body stuffer is often at risk for acute toxicity secondary to the fragile wrapping of the drug product as the packing is typically not intended for ingestion and transport such as the wrapping often used for body packing. However, if the packet ingested by a body packer ruptures, severe toxicity is significantly more probable.

The incidence and epidemiology of body packing and body stuffing is not well characterized; however, the practices have been noted to cross age, gender, and ethnic groups. Based on retrospective reviews of body stuffers, males were more frequently involved than females and the mean age across studies was approximately 33 years old. (3) Unfortunately, the literature has noted that children have been involved in this type of drug concealment, with a 12-year-old child found to have ingested 84 packets of heroin. (4,5)


Body stuffers and body packers generally present to health care providers for drug-induced toxidromes, medical assessment after detention or arrest, or intestinal obstruction. The conditions under which the patient presents will often guide the workup and management. Notably, in pediatric patients, Child Protective Services should be involved early in the course.

Obtaining History

Key questions to obtain in the history, if possible, are:

  1. What type of drug was ingested?
  2. When was the drug ingested?
  3. How many packets were ingested?
  4. How were the packets wrapped?
  5. Has the patient had symptoms of gastrointestinal obstruction or distress?
  6. Any other ingestions?

Physical exam

Generally, the physical examination should evaluate for signs of drug toxicity, intestinal obstruction, and the location of packets. As opposed to body packers, who tend to have drug packets expertly fashioned, (6) body stuffers commonly develop evidence of toxicity within hours of ingestion. Notably, as packets tend to leak before they rupture, signs and symptoms linked to a specific toxidrome should be noted early in the exam to anticipate potential devastating outcomes.

For cocaine ingestion, a sympathomimetic toxidrome should be identified, which includes tachycardia, hypertension, anxiety, agitation, diaphoresis, mydriasis, and later in the course, hyperthermia, seizures, and cardiovascular collapse. (7)

For heroin ingestion, findings of an opiate toxidrome may be identified, including bradypnea, depressed mental status, miosis, and decreased bowel sounds. (8)

Intestinal obstruction and perforation are more common in body packers than body stuffers. (9) Exam findings of obstruction, include emesis, high-pitched or absent bowel sounds, abdominal distension, and abdominal tenderness. If the patient’s abdomen reveals involuntary guarding, perforation should be suspected.

In terms of location of the drug packets, the physical examination is often not helpful. If suspected, rectal and vaginal examinations may disclose packets. The abdominal examination may reveal distention or palpable packets.

Diagnostic testing

Recommended testing includes an electrocardiogram; baseline bloodwork of CBC, BMP, LFTs, amylase, and blood gas; and an erect chest radiograph and abdominal radiograph. (9,10) If the patient endorses chest pain, a troponin should be obtained given possible cocaine-induced ischemia. Urine drug screening is generally not recommended as it is poorly sensitive, does not tend to change management, and is often misleading. (1,11)


A conventional radiograph should be obtained for all body packers. Specific findings include smooth, well-circumscribed foreign bodies that measure ~2.5cm, a “double condom sign,” and a “rosette-sign.” (12) However, because of the limited contrast resolution, its sensitivity for detecting drug packets ranges from 40–90% in body packers and significantly less so in body stuffers. (13,14)

Example of the "double condom" sign. Air trapping between latex seen at arrows. Credit: Dr. Frank Gaillard: Image obtained from Radiology Picture of the Day: Image modified with arrows. This work is licensed under a Creative Commons Attribution-Noncommercial 2.5 License.

Example of the "double condom" sign. Air trapping between latex seen at arrows.

Credit: Dr. Frank Gaillard: Image obtained from Radiology Picture of the Day: Image modified with arrows. This work is licensed under a Creative Commons Attribution-Noncommercial 2.5 License.

Generally, body stuffers do not require imaging. CT has been noted to be more sensitive than plain films for detecting drug packets and is often reserved for cases where abdominal plain films were negative but there is a high clinical suspicion for packing. In cases of suspected bowel obstruction, CT should be performed. Generally, oral and rectal contrast should be avoided as it can obscure packages because of similarities in density. (13)

Ultrasound has been proposed as an imaging modality as well, yet it has been noted to have a lower sensitivity than plain films. (12) Nevertheless, if perforation is suspected, ultrasound is an expedient way to determine if free fluid is present. 


All management should begin with the ABCs.

Disposition differs significantly between body stuffers and body packers.

Body stuffers

  • Asymptomatic patients should be observed for development of drug toxicity.
  • Recommendations for the duration of observation ranges from 6 to 24 hours from ingestion.7,14 However, the literature is primarily based on adult patients.
  • Activated charcoal (1 g/kg, up to 50 g) has been proposed for acute ingestion given its in-vitro ability to adsorb cocaine; however, clinical evidence is limited. (15)
  • Whole bowel irrigation, often used and recommended for body packers,16 has not been supported in the literature for body stuffers and often is not recommended.
  • In cases that are not straightforward and more complicated cases, such as ingestion of more than 10 pockets, poor history of events, and symptomatic patients, a Toxicologist or the Poison Control Center (1-800-222-1222) should be consulted.
  • Patients who are symptomatic may require surgical removal of retained packets and prompt surgical consultation if there are signs of obstruction, perforation, or if the patient’s toxidrome is unresponsive to medical therapy.
  • If surgical intervention is not needed, symptomatic patients should be admitted to a monitored setting based on their clinical status.

Body packers

  • The recommendation for asymptomatic patients is conservative management with monitoring in an ICU setting. (1,9)
  • Early surgery was recommended in the past for asymptomatic patients; however, as packet production has improved, the rate of rupture has declined.
  • Whole bowel irrigation with polyethylene glycol via an NG tube at a rate of 2 L/hr should be instituted.
  • Patients are eligible for discharge if they are asymptomatic AND have passed 3 packet-free bowel movements AND there is no radiologic evidence of internal packets remaining. (9) 
  • Patients with opioid toxicity should be treated with naloxone and may require very high doses.
  • Doses of naloxone are 0.01 mg/kg for infants and children younger than 5 years old or weighing less than 20 kg. Otherwise, doses range from 2-5 mg initially.
  • Higher initial doses of naloxone may be required and doses should be repeated every (5) minutes until responsive.
  • The total amount required for responsiveness should then be given every hour as a continuous drip.
  • Body packers presenting with sympathomimetic toxicity should be taken to the operating room for exploratory laparotomy – there is no medical antidote. (1)
  • Pharmacologic therapy with IV benzodiazepines with rapid up-titration and sodium bicarbonate for wide-complex tachycardias may should be given as the OR is prepared.
  • Patient’s with obstruction or perforation should also be taken for exploratory laparotomy.
  • Of note, body packers (and to some extent body stuffers) in legal custody may refuse to undergo invasive examinations and radiography; however, in most cases, they cannot refuse being medically cleared and discharged. (1)

Case Conclusion

The patient was admitted to the Pediatric floor, where he remained for 7 days. He received whole bowel irrigation, remained asymptomatic, had >3 bowel movements without any evidence of a drug packet, and had a CT scan showing no specific abnormalities. He was subsequently discharged home with his family.

Faculty Reviewer: Dr. Jane Preotle


1.     Traub SJ, Hoffman RS, Nelson LS. Body Packing — The Internal Concealment of Illicit Drugs. N Engl J Med. 2003;349(26):2519-2526.

2.     Bulstrode N, Banks F, Shrotria S. The outcome of drug smuggling by “body packers”--the British experience. Ann R Coll Surg Engl. 2002;84(1):35-38.

3.     Philip R, Aidayanti D. Uncommon Sites for Body Stuffing: A Literature Review. 2014.

4.     Beno S, Calello D, Baluffi A, Henretig FM. Pediatric Body Packing: Drug Smuggling Reaches a New Low. Pediatr Emerg Care. 2005;21(11):744.

5.     Traub SJ, Kohn GL, Hoffman RS, Nelson LS. Pediatric Body Packing. Arch Pediatr Adolesc Med. 2003;157(2):174-177.

6.     Pidoto RR, Agliata AM, Bertolini R, Mainini A, Rossi G, Giani G. A new method of packaging cocaine for international traffic and implications for the management of cocaine body packers. J Emerg Med. 2002;23(2):149-153.

7.     Sporer KA, Firestone J. Clinical course of crack cocaine body stuffers. Ann Emerg Med. 1997;29(5):596-601.

8.     Jordan MT, Bryant SM, Aks SE, Wahl M. A five-year review of the medical outcome of heroin body stuffers. J Emerg Med. 2009;36(3):250-256.

9.     Alfa-Wali M, Atinga A, Tanham M, Iqbal Q, Meng A-Y, Mohsen Y. Assessment of the management outcomes of body packers. ANZ J Surg. 2016;86(10):821-825.

10.   Beckley I, Ansari NAA, Khwaja HA, Mohsen Y. Clinical management of cocaine body packers: the Hillingdon experience. Can J Surg. 2009;52(5):417-421.

11.    Bogusz MJ, Althoff H, Erkens M, Maier RD, Hofmann R. Internally concealed cocaine: analytical and diagnostic aspects. J Forensic Sci. 1995;40(5):811-815.

12.    Lee K, Koehn M, Rastegar RF, et al. Body packers: the ins and outs of imaging. Can Assoc Radiol J J Assoc Can Radiol. 2012;63(4):318-322.

13.    Pinto A, Reginelli A, Pinto F, et al. Radiological and practical aspects of body packing. Br J Radiol. 2014;87(1036).

14.   June R, Aks SE, Keys N, Wahl M. Medical outcome of cocaine bodystuffers. J Emerg Med. 2000;18(2):221-224.

15.   Tomaszewski C, Voorhees S, Wathen J, Brent J, Kulig K. Cocaine adsorption to activated charcoal in vitro. J Emerg Med. 1992;10(1):59-62.

16.   Position paper: whole bowel irrigation. J Toxicol Clin Toxicol. 2004;42(6):843-854.

Header image: Credit: Dr. Frank Gaillard: Image obtained from Radiology Picture of the Day: Image modified with arrows. This work is licensed under a Creative Commons Attribution-Noncommercial 2.5 License.

AEM Early Access 08: The Pediatric Submersion Score

Welcome to the eighth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

   A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

   A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM


The Pediatric Submersion Score Predicts Children at Low Risk for Injury Following Submersions Shenoi RP, Allahabadi S, Rubalcava DM, Camp EA. 

(click on title for full text; open access through December 31st, 2017)     


listen now: Interview with lead author Dr. rohit shenoi

Rohit Shenoi.jpg

Dr Rohit Shenoi, MD

Associate Professor of Pediatrics
Baylor College of Medicine
Attending Physician, Emergency Center
Texas Children's Hospital



Unintentional submersion is a leading cause of death in children under 14 in the United States. From 2005-2014, over 3,500 people died per year in the United States from unintentional drowning.  A question for the emergency physician is what cohort of 'near-drowning' pediatric patients can be safely sent home from the emergency department following a period of observation.     

A single center retrospective cross sectional study of pediatric submersion patients attempted to provide insight and potential clinical scoring system to allow for safe discharge from the ED. At a tertiary-care pediatric emergency department, records were obtained containing demographics, comorbidities, EMS records, ED timeline, bounce back in 1 week period following visit and fatality records from 2008-2015. Primary outcome was safe discharge after 8-hour observation period. Safe discharge was defined by clinical parameters including normal mental status, normal vitals, normal pulmonary exam and no need for supplemental oxygen.     

Based on the data, a 5-point scoring system was created in order to objectively characterize patients who are safe for discharge. Included in the score are the following: normal mental status, respiratory rate, absence of dyspnea, no requirement for airway support, no documented hypotension. The author reports a score of 4 or greater safe for discharge.     

Although the variables presented by the pediatric submersion score are largely intuitive, the score gives objective criteria to potentially augment disposition decision making process within the ED. A universal guideline for ED management of pediatric submersions does not exist. Recent literature has only provided patient variables that predict safe discharge. In the AEM article recently published, a retrospective cohort study of pediatric submersion found lack of need for supplemental oxygen and lack of field intervention were independent predictors of safe ED discharge. The pediatric submersion score may be most useful for the inexperienced provider or emergency departments where submersion injuries are seen infrequently. Ultimately, the pediatric submersion score provides some evidence in the literature regarding management of low risk submersion victims.

FURTHER READINg/resources:

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS).

CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016.

Predictors of emergency department discharge following pediatric drowning. Cantu RM, Pruitt CM, Samuy N, Wu CL.Am J Emerg Med. 2017 Sep 4. pii: S0735-6757(17)30722-2. doi: 10.1016/j.ajem.2017.08.057.