UMEM Educational Pearls

Category: Toxicology

Title: A Bad Natural "High"

Keywords: Anticholinergic, Plant (PubMed Search)

Posted: 9/20/2018 by Kathy Prybys, DO
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A 19 year old male presents confused and very agitated complaining of seeing things and stomach pain. His friends report he ingested a naturally occurring plant to get high a few hours ago but is having a "bad trip".  His physical exam :

Temp 100.3, HR 120, RR 14, BP 130/88. Pulse Ox 98%.

Skin: Dry, hot , flushed

HEENT: Marked mydriasis 6mm

Lungs: Clear

Heart: Tachycardic

Abdomen: Distended tender suprapubic with absent bowel sounds,

Neuro: Extremely agitated pacing, no muscular rigidity.

What has he ingested and what is the treatment?


Image result for jimson weedDatura stramonium, aka: Jimson Weed, flowers in the summer with white to violet trumpet petals, green irregular toothed leaves, and a  green thorny round walnut sized seed pod (aka: thorn apple) the base of the stem. In the fall, the seed pods turn brown and split open to reveal chambers that are packed with dozens of small black seeds containing the anticholinergic tropane alkaloids, atropine, hyoscyamine, and scopolamine. 

All parts of the plant are toxic and it has long been used in traditional medicine. Toxicity consists of anticholinergic toxidrome: Delirium and agitation, visual hallucinations, dry flushed skin, hyperthermia, mydriaisis, tachycardia, absent bowel sounds, urinary retention, remembered by the pneumonic "Red as a beet, hot as a hare, dry as a bone, blind as a bat, mad as a hatter, the bowel and bladder lose their tone, and the heart runs alone" . Toxicity is usually 12 hours but can be quite prolonged.

Treatment consists of :

-Gastric decontamination with activated charcoal and whole bowel irrigation for seed ingestion (seeds get caught up in gastric folds prolonging toxicity)

-IV Physostigmine, a reversible short acting acetylcholinesterase inhibitor increases acetylcholine at the synaptic clef, crosses the blood brain barrier, and is antidotal. Physostigmine has been demonstrated to be more effective and without significant complications when compared with benzodiazepines for the diagnosis and treatment of anticholinergic agitation and delirium. Usual dose is 0.5-2 mg with repeat dosages as  needed.


Anticholinergic syndrome induced by toxic plants. Soulaidopoulos S,Sinakos E,  et al. World Journal of Emergency Medicine. 2017;8(4):297-301. 
Anticholinergic delirium following Datura stramonium ingestion:Implications for the Internet age. Vearrier D, Greenberg MI.J Emerg Trauma Shock. 2010;3(3):303.
 A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning. Burns MJ, Linden CH, et al. Ann Emerg Med.2000;35(4):374-81.
Complications of diagnostic physostigmine administration to emergency department patients. Schneir AB, Offerman SR, et al. Ann Emerg Med. 2003 Jul;42(1):14-9.