1. ANTICHOLINERGIC PLANT POISONING Dr. Roshan Karki

7. ANTICHOLINERGIC PLANT POISONING TROPANE ALKALOIDS – found in all parts of plant, with highest concentrations in roots and seeds Hyoscyamine Hyoscine (Scopolamine) Atropine Mandragorine PLANTS CONTAINING TROPANE ALKALOIDS Dhatura spp. a common recreational hallucinogen Hyoscyamus niger Atropa belladonna Mandragora officinarum Brugmansia spp. Lycium halimiforium Cestrum nocturnum

14. EPIDEMIOLOGY: Incidence: No national data Common poisoning Usually sporadic, but may occur in clusters Mode of poisoning: ~ recreational overdose ~ ingestion of contaminated foods such as Paraguay tea, hamburger, honey , homemade ‘moonflower’ wine or stiff porridge made from contaminated millet ~ accidental ingestion as edible wild vegetable Mortality: Death rare ( 1993 CDC data reports 2 deaths among 318 cases of Dhatura poisoning in US)- due to trauma sustained during delirium

16. Signs Vital signs Tachycardia Hypertension Elevated temperature - hyperthermia HEENT Mydriasis and cycloplegia Dry mucous membrane Skin Warm, dry and flushed Neurological Altered mental status- Agitation Delirium (acute confusional state + hallucination) Muscle inco-ordination, respiratory depression, seizures and coma (rare) Abdomen Diminished bowel sounds Distended urinary bladder

17. INVESTIGATION: No specific diagnostic studies exist- TIME SHOULD NOT BE WASTED IN ATTEMPTING TO IDENTIFY PLANTS Physostigmine test : if relative certainty cannot be established that toxicity present is due to tropane alkaloid poisoning. It precludes unnecessary CT head and LP. Toxicological analyses is useful in sporadic cases only if co-ingestion of other substance most commonly acetaminophen and salicylate is suspected. ECG if there is marked tachycardia CPK and Urinalysis : if rhabdomyolysis is suspected Blood urea, Serum creatinine, Na and K : to rule out prerenal ARF

18. TREATMENT Principles: 1 . Control of Agitation 2. Protection from self harm EMERGENCY DEPARTMENT CARE Follow ABCDE of Emergency Medicine Consider GI Decontamination foremost 1.Emesis by Ipecac- contraindicated 2.Gastric Lavage-controversial (increased risk of aspiration!) 24-32 F tube in children 36-42 F tube in adult 3. Activated Charcoal- useful 1-2g/kg po or via nasogastric/orogastric tube Can be repeated after 4-6 hrs

19. Treatment is largely SUPPORTIVE! Agitation/Hallucination: Reassurance Dark room Chemical restraint with Benzodiazepines Diazepam 5-10mg IV (adults) 0.2-0.5mg/kg IV (children) Lorazepam 1-2mg IV (adults) 0.05mg IV (children) HALOPERIDOL IS CONTRAINDICATED ! Physical restraint – risk of rhabdomyolysis Seizures Diazepam Phenobarbitone Urinary retention Foley catheterisation Urine output should be maintained at 1-2ml/kg/hr

20. Use of Specific Antidote – PHYSOSTIGMINE- is controversial (risk of cholinergic crisis) Indications: 1. Unresponsive to supportive treatment 2. Tachyarrhythmias with hemodynamic compromise 3. Intractable seizures unresponsive to benzodiazepine 4. Extremely sever agitation or psychosis Hemodialysis and Hemoperfusion is not useful because of high lipid solubility of tropane alkaloids

21. DISPOSITION: Asymptomatic patients – discharged after 4-6 hrs of observation Symptomatic patients – admitted in ICU setting for monitoring and treatment; and discharged after a symptomfree interval of 6 hrs without supportive treatment or antidote. (symptoms may persist for 24-48hrs)

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