Datura vs Cocaine Poisoning: Key Differences in Management
Datura poisoning requires anticholinergic toxidrome management with physostigmine for severe cases, while cocaine poisoning demands benzodiazepines as first-line therapy with sodium bicarbonate for cardiac dysrhythmias—these are fundamentally different treatment approaches for opposite toxidromes.
Toxidrome Recognition
Datura (Anticholinergic Toxidrome)
- Classic presentation: Delirium, visual and auditory hallucinations, mydriasis, dry mouth, urinary retention, hyperthermia, tachycardia, flushed skin, and agitation 1, 2, 3
- Mnemonic features: "Hot as a hare, blind as a bat, dry as a bone, red as a beet, mad as a hatter" 2
- Onset: Symptoms typically appear 15-30 minutes after ingestion 2
- Mechanism: Atropine and scopolamine block muscarinic acetylcholine receptors 1, 3
Cocaine (Sympathomimetic Toxidrome)
- Classic presentation: Agitation, diaphoresis, tachycardia, hypertension, hyperthermia, seizures, increased psychomotor activity, and potential wide-complex dysrhythmias 4, 5
- Cardiac effects: QRS prolongation from sodium channel blockade, QT prolongation from potassium channel blockade 4
- Mechanism: Catecholamine reuptake inhibition causing sympathetic surge plus local anesthetic effects on cardiac sodium channels 4
Critical First-Line Management Differences
Datura Poisoning
- Supportive care is primary: Restraint, IV fluids, and symptomatic management for most cases 1, 2, 3
- Physostigmine for severe cases: Reserved for patients with delirium, coma, or life-threatening agitation—reverses central and peripheral anticholinergic effects 2, 3
- Dose: Typically 1-2 mg IV slowly (not specified in evidence but standard practice)
- Response is dramatic: Three of four patients with delirium/coma showed good response 2
- Foley catheterization: Often needed for urinary retention 2, 3
- Antipsychotics: Cyamemazine was successfully used in two cases for severe agitation and hallucinations 1
- Intubation: May be required for coma with respiratory depression 2
Cocaine Poisoning
- Benzodiazepines are mandatory first-line: Lorazepam 2-4 mg IV or diazepam 5-10 mg IV immediately to reduce sympathetic activation 4, 6, 7, 5
- Sodium bicarbonate for dysrhythmias: 1-2 mEq/kg IV bolus for wide-complex tachycardia or cardiac arrest (Class 2a recommendation) 4, 7
- Lidocaine is reasonable: For wide-complex tachycardia through competitive sodium channel binding 4
- Vasodilators for refractory hypertension: Phentolamine, nitrates, or calcium channel blockers—NOT beta-blockers 4, 6, 7
Life-Threatening Complications Management
Hyperthermia (Both Toxins)
- Datura: Supportive cooling measures 2, 3
- Cocaine: Rapid external cooling using evaporative or immersive methods (Class 1 recommendation)—cooling blankets are inadequate 4, 7
Seizures
- Datura: Rare; standard anticonvulsant management if occurs 2
- Cocaine: Benzodiazepines are critical—seizures are a major determinant of lethality and must be controlled immediately 5
Cardiac Arrest
- Datura: Rare (fatal in >5% of cases); standard ACLS 1
- Cocaine: Standard ACLS plus sodium bicarbonate for wide-complex rhythms; avoid pure beta-blockers 4, 7
Critical Pitfalls to Avoid
Datura-Specific
- Do not miss the diagnosis: Patients and companions rarely volunteer information about plant ingestion—consider in any adolescent/young adult with unexplained anticholinergic features 1
- Lethal dose proximity: Atropine levels of 1.7 ng/mL (near-lethal) can occur with recreational use 1
- Duration: Symptoms typically resolve in 36-40 hours with supportive care 1
Cocaine-Specific
- NEVER use pure beta-blockers: Propranolol, metoprolol, or esmolol cause unopposed alpha-adrenergic stimulation, worsening coronary vasospasm and hypertension (Class 3 harm) 4, 6, 7, 8
- Avoid beta-blockers for 72 hours: Even after acute phase 7, 8
- Acidosis correction is essential: Severe metabolic and respiratory acidosis must be treated with ventilation and bicarbonate to normalize cardiac rhythm 5
- Beware hypotension: Cocaine's effects are transient (minutes to hours), but treatment effects persist—titrate carefully 7, 8
Antidote Summary
| Toxin | Specific Antidote | Indication | Class of Recommendation |
|---|---|---|---|
| Datura | Physostigmine | Severe delirium, coma, life-threatening agitation | Not graded in evidence but effective [2,3] |
| Cocaine | Sodium bicarbonate | Wide-complex tachycardia or cardiac arrest | Class 2a [4] |
| Cocaine | Benzodiazepines | All cases with agitation, tachycardia, hypertension | Class 2a [4,6,7] |
Monitoring and Disposition
Datura
- Hospital admission: 2-4 days for severe cases 1, 2, 3
- Recovery: Usually complete with no sequelae despite severe presentation 2, 3
- Toxicology confirmation: LC-MS/MS can detect atropine and scopolamine levels 1
Cocaine
- Continuous cardiac monitoring: Essential for all patients with cardiovascular symptoms 6, 7
- High-risk features requiring admission: ST-segment changes ≥1 mm, elevated troponin, recurrent chest pain, hemodynamic instability 7
- Screen for complications: Aortic dissection, coronary dissection, myocarditis, cardiomyopathy 7