Management of Datura (Jimson Weed) Poisoning
Datura poisoning requires immediate supportive care with benzodiazepines for agitation and seizures, physostigmine as the specific antidote for severe anticholinergic toxicity, and aggressive monitoring for life-threatening complications including respiratory failure and hyperthermia. 1, 2, 3
Immediate Recognition and Stabilization
Clinical Presentation (Anticholinergic Toxidrome)
Datura contains atropine, scopolamine, and hyoscyamine, producing classic anticholinergic syndrome with both central and peripheral manifestations 2, 4:
Central effects:
- Visual and auditory hallucinations (most common presenting symptom) 4, 5
- Delirium, confusion, and agitation 4, 3
- Disorientation and anxiety 2, 3
- Seizures in severe cases 2
- Coma and respiratory depression (>5% of cases can be fatal) 4, 6
Peripheral effects:
- Tachycardia (universal finding) 2, 3, 6
- Mydriasis (dilated pupils) 2, 3
- Hyperthermia 2, 3, 6
- Dry mouth and flushed skin 2, 3
- Urinary retention 2, 3, 6
- Decreased bowel sounds 2
Priority Supportive Care
Airway management takes absolute priority - intubate immediately for coma, respiratory depression, or inability to protect airway 1, 6. One case series documented need for rapid sequence intubation and mechanical ventilation within hours of presentation 6.
Contact poison control immediately (1-800-222-1222 in US) for expert toxicology guidance 1, 7.
Decontamination:
- Remove contaminated clothing and wash skin thoroughly with soap and water 7
- Activated charcoal may be considered if presentation is within 1-2 hours of ingestion and airway is protected, though evidence is limited 6
- Do NOT induce vomiting 7
Specific Pharmacologic Management
Benzodiazepines (First-Line for Agitation/Seizures)
Administer benzodiazepines immediately for seizures, severe agitation, or delirium 1, 7. The American Heart Association gives this a Class 1, Level C-LD recommendation for anticholinergic poisoning 1.
- Diazepam is first-line; midazolam is alternative 1
- Multiple case reports document successful management with benzodiazepines alone for moderate toxicity 4, 3
- Cyamemazine (antipsychotic) was used successfully in French case series, though benzodiazepines remain preferred 4
Physostigmine (Specific Antidote)
Physostigmine is the definitive antidote for severe anticholinergic toxicity from Datura poisoning 2, 3. This reversible anticholinesterase crosses the blood-brain barrier and reverses both central and peripheral anticholinergic effects 2.
Indications for physostigmine:
- Severe delirium or hallucinations not controlled by benzodiazepines 3
- Coma from anticholinergic toxicity 3
- Life-threatening hyperthermia 2
- Seizures refractory to benzodiazepines 2
Dosing:
- Adults: 0.5-2 mg IV slowly (no faster than 0.5 mg/minute), may repeat every 5-10 minutes until therapeutic effect or maximum 2 mg 2
- Pediatric: 0.02 mg/kg IV slowly (no faster than 0.5 mg/minute), may repeat every 5-10 minutes until therapeutic effect or maximum 2 mg total 2
- Duration of action is 45-60 minutes; repeat dosing often necessary 2
Clinical response: Dramatic reversal of anticholinergic symptoms occurs within minutes if diagnosis is correct 2. Case series documented good response in patients with delirium/coma 3.
Critical contraindications to physostigmine:
- Cardiac conduction abnormalities (including bundle branch blocks) 6
- Asthma or reactive airway disease 2
- Mechanical bowel or bladder obstruction 2
Important caveat: One case report used neostigmine infusion instead, but this quaternary amine does NOT cross the blood-brain barrier and will not reverse central effects 2, 6. This was likely suboptimal management.
Monitoring and Complications Management
Cardiovascular Monitoring
- Continuous cardiac monitoring for tachycardia and dysrhythmias 3, 6
- One case documented right bundle branch block, which would contraindicate physostigmine 6
- Monitor blood pressure (hypertension can occur) 3
Temperature Management
Aggressive cooling for hyperthermia using both external (ice packs, cooling blankets) and internal methods (cold IV fluids) 6. Hyperthermia significantly increases morbidity and mortality 2.
Urinary Retention
- Foley catheterization frequently required for urinary retention or coma 3
- Monitor for urinary tract infection as complication 3
Rhabdomyolysis
- Check creatine kinase, especially with hyperthermia or prolonged agitation 6
- Aggressive IV hydration to prevent acute kidney injury 6
Duration of Symptoms
- Symptoms typically resolve within 24-48 hours with supportive care 4, 3
- Visual accommodation difficulties may persist for days 8
- Amnesia about the episode can last months 8
- Atropine levels near lethal range (1.7 ng/mL) documented at 12 hours post-ingestion 4
- Scopolamine detectable in blood for 48+ hours 4
Common Pitfalls to Avoid
Do not delay treatment waiting for toxicology confirmation - diagnosis is clinical based on anticholinergic toxidrome 1, 7, 4. Liquid chromatography-mass spectrometry can confirm diagnosis but is not available emergently in most hospitals 4.
Do not use physostigmine in patients with cardiac conduction abnormalities - check ECG first 6.
Do not use neostigmine as substitute for physostigmine - it does not cross blood-brain barrier and will not reverse central anticholinergic effects 2, 6.
Do not underestimate severity - lethal concentration is close to the level causing delirium, with >5% mortality rate in severe cases 4.
Recognize that patients/companions often withhold drug use history - maintain high index of suspicion in adolescents or young adults with unexplained agitation, hallucinations, and anticholinergic signs 4, 8.
Anticipate repeat use - while most patients find the experience unpleasant and do not repeat it, harm reduction counseling is essential 8.