Management of Datura Poisoning
Immediately secure the airway with intubation for any patient with coma, respiratory depression, or inability to protect their airway, and administer benzodiazepines as first-line treatment for agitation, delirium, or seizures, reserving physostigmine as the definitive antidote for severe anticholinergic toxicity refractory to benzodiazepines. 1
Immediate Stabilization and Recognition
Airway Management
- Intubate immediately if the patient presents with coma, respiratory depression, or inability to protect their airway 1
- Rapid sequence intubation should be performed for patients in coma, as Datura poisoning can cause severe CNS depression requiring mechanical ventilation 2
- Contact poison control (1-800-222-1222 in the US) immediately for expert toxicology guidance 1
Clinical Recognition
The diagnosis is clinical based on the anticholinergic toxidrome—do not delay treatment waiting for toxicology confirmation 1. Look for:
- Central effects: Agitation, delirium, visual and auditory hallucinations, confusion, seizures, or coma 3, 4, 5
- Peripheral anticholinergic signs: Mydriasis, dry mouth, flushed skin, tachycardia, hyperthermia, urinary retention 4, 6
- Cardiovascular: Tachycardia, arrhythmias (including right bundle branch block), hypertension 4, 2
Pharmacologic Management
First-Line: Benzodiazepines
- Administer benzodiazepines immediately for seizures, severe agitation, or delirium (Class 1, Level C-LD recommendation) 7, 1
- Diazepam is first-line, with midazolam as an alternative 7, 1
- This represents the initial pharmacologic intervention before considering physostigmine 1
Definitive Antidote: Physostigmine
Physostigmine is the definitive antidote for severe anticholinergic toxicity from Datura poisoning 1.
Specific indications for physostigmine include:
- Severe delirium or hallucinations not controlled by benzodiazepines 1
- Coma 1
- Life-threatening hyperthermia 1
- Seizures refractory to benzodiazepines 1
- Clinical evidence shows good response in patients with delirium/coma 4
Dosing (from FDA label):
- Pediatric: 0.02 mg/kg IM or slow IV (no faster than 0.5 mg/minute), maximum 0.5 mg per dose 8
- May repeat at 5-10 minute intervals if toxic effects persist without cholinergic signs, up to maximum 2 mg total 8
- Alternative regimen: Neostigmine infusion has been used successfully in severe cases 2
Supportive Measures
- Gastrointestinal decontamination: Activated charcoal in repeated doses if presenting early 5, 2
- Hyperthermia management: External and internal cooling as needed 2
- Urinary retention: Foley catheterization may be required 4
- Fluid therapy: Standard supportive IV fluids for all patients 4
Monitoring and Complications
Critical Monitoring Parameters
- Continuous cardiac monitoring for arrhythmias and conduction abnormalities 4, 2
- Temperature monitoring as hyperthermia is common and can be life-threatening 4, 2
- Rhabdomyolysis screening: Check creatine kinase and renal function, as rhabdomyolysis can occur requiring prevention of renal failure 2
- Urinary output: Monitor for retention requiring catheterization 4
Duration and Prognosis
- Symptoms typically begin 15-30 minutes after ingestion 4
- Recovery usually occurs within 36-40 hours with appropriate treatment 3
- Prognosis is generally favorable with early recognition and treatment 5
- Severe complications (coma, respiratory distress, death) occur in more than 5% of cases, as the lethal concentration is close to the delirium-inducing level 3
Common Pitfalls
Critical caveat: Blood levels of atropine and scopolamine can reach near-lethal concentrations (1.4-1.7 ng/mL) even in patients who ultimately recover, emphasizing the importance of aggressive supportive care 3. The narrow margin between toxic and lethal doses makes early intervention essential.
Do not assume voluntary disclosure: Patients and companions rarely volunteer information about Datura ingestion, so maintain high clinical suspicion in any adolescent or young adult presenting with unexplained agitation and confusion 3.