Dhatura poisoning mangement
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Dhatura datura poisoning management treatment
Harrison's Principles of Internal Medicine, Twenty First Edition
Page 13018
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anticholinergic poisoning clinical features diagnosis antidote physostigmine
Harrison's Principles of Internal Medicine, Twenty First Edition
Page 13018
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The retrieved results provide general poisoning principles. Let me now compile a comprehensive answer drawing on these findings plus my structured medical knowledge on Dhatura (anticholinergic) poisoning.
Dhatura (Datura) Poisoning — Management
Background
Datura stramonium (Dhatura/Jimsonweed/Thorn apple) contains tropane alkaloids — atropine, hyoscine (scopolamine), and hyoscyamine — all potent anticholinergic (antimuscarinic) agents. Every part of the plant (seeds, leaves, flowers, roots) is toxic; seeds are the most commonly ingested.
Clinical Features — "Anticholinergic Toxidrome"
| System | Features |
|---|---|
| CNS | Agitation, delirium, hallucinations (visual > auditory), confusion, seizures, coma |
| Eyes | Mydriasis (dilated pupils), blurred vision, photophobia |
| CVS | Tachycardia, palpitations, hypertension |
| Skin/Mucosa | Dry, flushed, hot skin; dry mouth |
| GI | Decreased bowel sounds, ileus, nausea |
| GU | Urinary retention |
| Temperature | Hyperthermia |
Mnemonic: "Blind as a bat, Dry as a bone, Red as a beet, Mad as a hatter, Hot as Hades, Full as a flask"
Management
1. Stabilization (ABCs)
- Airway: Secure airway if GCS is depressed or seizures present; intubate if needed.
- Breathing: Supplemental O₂; monitor SpO₂.
- Circulation: IV access, cardiac monitoring (ECG for tachyarrhythmias), IV fluids.
- Place the patient in a calm, dark, quiet room to reduce agitation and sensory stimulation.
2. Decontamination
- Gastric lavage: If presentation is within 1–2 hours of ingestion and airway is protected. Dhatura slows gastric emptying (anticholinergic effect), so may be beneficial slightly beyond the usual window.
- Activated charcoal (AC): 1 g/kg orally (max 50–100 g) if the patient is alert and cooperative with protected airway. Binds alkaloids effectively.
- Emesis is contraindicated — rapid CNS deterioration can compromise airway.
3. Specific Antidote — Physostigmine
Physostigmine is a reversible cholinesterase inhibitor that crosses the blood-brain barrier, reversing both central and peripheral anticholinergic effects (Harrison's, p. 13018).
| Parameter | Detail |
|---|---|
| Indication | Severe agitation, delirium, seizures, or refractory tachycardia unresponsive to supportive care |
| Dose (adult) | 1–2 mg IV slowly over 5 minutes; may repeat 1–2 mg after 20 minutes |
| Dose (child) | 0.02 mg/kg IV slowly (max 0.5 mg); may repeat every 5–10 min (max total 2 mg) |
| Onset | 5–15 minutes |
| Duration | 30–60 minutes (repeat dosing often needed) |
| Contraindications | Asthma, COPD, cardiac conduction defects, mechanical obstruction, gangrene, concurrent TCA/depolarizing NMJ blockers |
| Adverse effects | Bradycardia, bronchospasm, seizures (if given rapidly or in overdose) |
Always have atropine at bedside when giving physostigmine (to reverse cholinergic crisis if it occurs).
4. Symptomatic & Supportive Care
| Problem | Management |
|---|---|
| Agitation/delirium | Benzodiazepines (lorazepam 1–2 mg IV); avoid physical restraints (worsen hyperthermia) |
| Seizures | Benzodiazepines (first line); phenobarbital or propofol if refractory |
| Hyperthermia | External cooling (ice packs, cooling blanket, tepid sponging); target <38.5°C |
| Tachycardia | Usually resolves with physostigmine; benzodiazepines also help |
| Urinary retention | Urinary catheterization |
| Hypotension | IV crystalloids; vasopressors if refractory |
| Hallucinations | Low-dose haloperidol (butyrophenones preferred over phenothiazines) |
Avoid phenothiazines (chlorpromazine) — they have additive anticholinergic effects.
5. Investigations
- Blood glucose (exclude hypoglycemia as cause of altered sensorium)
- Serum electrolytes, renal function, LFT
- ECG — QTc prolongation, tachyarrhythmias
- ABG — if respiratory compromise
- Urine — for toxicology screen (optional; diagnosis is clinical)
- Core temperature monitoring
6. Monitoring & Disposition
- ICU/HDU admission for moderate-to-severe cases.
- Monitor for at least 24 hours — alkaloid absorption can be prolonged (anticholinergic gut stasis delays further absorption).
- Resolution of symptoms typically occurs within 24–48 hours.
- Psychiatric evaluation after recovery if intentional ingestion.
Summary Algorithm
Suspected Dhatura Poisoning
↓
Stabilize ABCs + IV access + ECG
↓
Decontamination (AC ± gastric lavage if <2h, airway protected)
↓
Assess severity
├── Mild (dry mouth, mydriasis, mild tachycardia)
│ → Observe, supportive care, fluids
└── Moderate-Severe (delirium, seizures, hyperthermia, severe tachycardia)
↓
Benzodiazepines for agitation/seizures
Physostigmine (1–2 mg IV slowly) — with atropine at bedside
Cooling measures for hyperthermia
Urinary catheterization
↓
ICU monitoring ≥24 hours
Key teaching point: Dhatura poisoning is a clinical diagnosis based on the anticholinergic toxidrome. Physostigmine serves both as a diagnostic tool and a therapeutic agent — complete reversal of symptoms confirms anticholinergic etiology (Harrison's, p. 13018).
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