What is the management for Datura poisoning?

Management of Datura Poisoning

The management of Datura poisoning requires immediate supportive care, activated charcoal for decontamination, and physostigmine (0.02 mg/kg IV/IM) as a specific antidote for severe anticholinergic toxicity. 1, 2

Clinical Presentation

Datura poisoning presents with an anticholinergic toxidrome characterized by:

• Central nervous system effects: confusion, delirium, hallucinations, agitation, coma
• Peripheral effects: mydriasis, tachycardia, hyperthermia, dry mouth, dry skin, urinary retention
• "Hot as a hare, blind as a bat, dry as a bone, red as a beet, mad as a hatter" 3, 4, 5

Management Algorithm

1. Initial Stabilization

• Secure airway: Early endotracheal intubation for severe poisoning or altered mental status
• Support breathing: Provide mechanical ventilation as needed
• Maintain circulation: IV fluids for hypotension, position unconscious patients in left lateral head-down position
• Continuous cardiac monitoring 1

2. Decontamination

• Administer activated charcoal in repeated doses (within 1-2 hours of ingestion)
• Do not induce vomiting or administer anything by mouth unless advised by poison control 1, 3

3. Specific Antidote

• Physostigmine for severe anticholinergic toxicity:
  • Adult dose: 0.5-2 mg IV slowly (no more than 0.5 mg per minute)
  • Pediatric dose: 0.02 mg/kg IM or slow IV
  • May repeat at 5-10 minute intervals if toxic effects persist and no cholinergic effects appear
  • Maximum total dose: 2 mg 2, 4

4. Supportive Care

• Cooling measures for hyperthermia (external and internal cooling)
• IV fluids for hydration and to maintain blood pressure
• Benzodiazepines for agitation and seizures
• Monitor for and treat rhabdomyolysis to prevent renal failure
• Bladder catheterization for urinary retention 1, 3

Evidence for Physostigmine Use

Physostigmine is particularly effective for Datura poisoning because:

• It crosses the blood-brain barrier and reverses both central and peripheral anticholinergic effects
• Studies show earlier resolution of central nervous system toxicity in patients who received physostigmine compared to those who did not 4
• No adverse events were reported from physostigmine administration in a study of Datura poisoning cases 4

Contraindications to Physostigmine

Exercise caution with physostigmine in patients with:

• Cardiovascular disease
• Asthma
• Mechanical obstruction of intestine or urinary tract
• Concurrent use of cholinesterase inhibitors 2

Duration of Monitoring

• Patients should be monitored for at least 24-36 hours after ingestion
• Anticholinergic effects may persist for days, particularly visual accommodation difficulties 3, 6
• Continuous cardiac monitoring is essential due to risk of dysrhythmias 1

Additional Considerations

• Contact regional poison centers for expert guidance (US: 1-800-222-1222) 7, 1
• Datura poisoning can be accidental (medicinal use, misidentification) or intentional (recreational use, criminal poisoning) 4, 8
• Parts of the plant other than flowers are associated with more severe poisoning 4

Pitfalls to Avoid

• Delaying antidote administration while waiting for confirmatory testing
• Failing to recognize the anticholinergic toxidrome
• Discharging patients too early (symptoms can persist or recur)
• Overlooking the possibility of co-ingestants or adulterants 1