Poisoning due to Angel’s Trumpet / Datura stramonium / Bunga Terung

The plant contains belladonna alkaloids – atropine, scopolamine and hyoscyamine – in the seeds, roots, flowers and stems, whose primary actions are anticholinergic.

Mechanism of Action  

• competitive blockade of acetylcholine at muscarinic receptors, both centrally and peripherally, as well as at end organ sites of the parasympathetic nervous system
• The signs and symptoms of acute anticholinergic activity usually appear within 1 h to 4 h postingestion.

Signs and Symptoms

• Dry mouth, thirst, blurred vision and photophobia, and appear confused and restless
• Their skin may look flushed and dry.
• Become aggressive and may appear to be experiencing amphetamine intoxication
• Delirium, hallucinations and hyperactivity.
• Delirium is usually of quick onset, and has manifestations of fluctuating level of orientation, self-regulation, memory and impulse control.
• In severe cases, seizures and coma may develop.
• Physical examination findings may include tachypnea, tachycardia, hyper- or hypotension, hyperpyrexia, dry mucous membranes, and dry and flushed skin.
• Bowel sounds may be decreased and urinary retention is common.
• Examination of the eyes reveal mydriasis and cycloplegia, can persist for days 

Treatment

• largely supportive

Benzodiazepines

• Agitation should be controlled by titrating intravenous benzodiazepines to sedation. Benzodiazepines are recommended over phenothiazines and butyrophenones because exacerbation or induction of hypotension is unlikely, the possibility of seizures is decreased and anti-cholinergic effects are absent.
• Sedation of the agitated patient allows for easier physical restraint. It also prevents self-injury, severe hyperthermia and the development of myoglobinuric renal failure from muscle injury

Haloperidol

• Haloperidol should be used cautiously in acute Angel’s Trumpet poisoning because it may cause acute dystonia and other movement disorders.
• Activated charcoal
• most useful in the first hour after ingestion. Early gastric emptying should be considered for large ingestions of an initially asymptomatic patient or in an intubated patient, regardless of the time of ingestion

Physostigmine

• Role of physostigmine has been controversial. This is due to the potential adverse effects of physostigmine secondary to acetylcholine accumulation ( seizures, muscle weakness, bradycardia, lacrimation, salivation, bronchorrhea, diarrhea and asthma exacerbation)
• treat antocholinergic symptoms such as delirium, coma, severe agitation and symptomatic supraventricular tachycardia.
• To minimize toxicity, physostigmine should be infused over 5 min in an initial dose of 0.02 mg/kg (maximum 0.5 mg) for children to control severe anticholinergic manifestations.
• can be repeated as needed
• Atropine should be available and the infusion stopped immediately if signs of cholinergic excess appear

References:

1. Angel’s Trumpet (Datura stramonium) poisoning and delirium in adolescents in Winnipeg, Manitoba: Summer 2006. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2529415/
2. http://thepoisondiaries.tumblr.com/post/16112809580/hazard-deadly-poison-datura
3. Angel's Trumpet. http://www.rxlist.com/angels_trumpet/supplements.htm