Conditions · Emergency medicine and toxicology
Anticholinergic toxicity (incl. scopolamine «burundanga») !
Drugs and plants that block acetylcholine cause hot dry skin, big pupils, fast pulse, urine retention and confusion; scopolamine is used in crimes.
Updated 2026-11-01
Structures involved
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Why it happens
- Adrenergic and cholinergic receptors
- Sympathetic and parasympathetic effects on each organ
- Body temperature regulation
What it is
A toxidrome caused by antagonism of muscarinic acetylcholine receptors. Classic sources are scopolamine (from Brugmansia, «borrachero», and Datura plants), atropine, antihistamines, tricyclic antidepressants, antipsychotics, antispasmodics and antiparkinsonian drugs. In Colombia, scopolamine («burundanga») is used to make victims compliant and amnesic for robbery or sexual assault.
Who gets it
Scopolamine intoxication related to crime is a recognised public-health and security problem in Colombia, especially in large cities, and is often combined with benzodiazepines or phenothiazines. Brugmansia and Datura grow widely in the Andes. Accidental poisoning from antihistamines and plants also occurs in children, and older adults are vulnerable to cumulative anticholinergic drugs.
Causes
- Scopolamine given covertly in drinks, food, cigarettes or powder blown at the face
- Ingestion of Brugmansia or Datura (flowers, seeds, teas) for recreational or ritual use
- Overdose of antihistamines, tricyclic antidepressants, antipsychotics or antispasmodics
- Atropine excess during treatment of cholinergic poisoning
Risk factors
- Accepting drinks or food from strangers; nightlife and tourism settings
- Older age and polypharmacy with anticholinergic drugs
- Children with access to medicines or garden plants
- Recreational use of hallucinogenic plants
Pathophysiology
Competitive blockade of muscarinic receptors removes parasympathetic tone. Peripherally this gives mydriasis and loss of accommodation, tachycardia, dry skin and mucosa (no sweating, so heat cannot be lost), reduced gut motility and urinary retention. Centrally, tertiary amines such as scopolamine cross the blood–brain barrier and cause agitated delirium, hallucinations, anterograde amnesia, myoclonus, seizures and coma. Scopolamine is cleared quickly, which makes laboratory confirmation difficult.
Classification
- Peripheral syndrome: mydriasis, tachycardia, dry flushed skin, urinary retention, ileus
- Central syndrome: agitation, delirium, hallucinations, amnesia, seizures, coma
- Mixed presentations, common with scopolamine plus sedatives
Symptoms and signs
- Hot, dry, red skin and dry mouth («hot as a hare, dry as a bone, red as a beet»)
- Dilated pupils and blurred vision («blind as a bat»)
- Fast heart rate and fever
- Urinary retention and absent bowel sounds
- Agitation, picking at the air, hallucinations and incoherent speech («mad as a hatter»); amnesia for events
- Unusual compliance and suggestibility in scopolamine-facilitated crime
Diagnosis
- Clinical
- Clinical diagnosis based on the toxidrome. Dry skin and urinary retention distinguish it from sympathomimetic toxicity, in which the skin is sweaty. A palpable bladder and absent bowel sounds support the diagnosis. In suspected criminal use, document findings carefully, preserve samples early and activate the legal and sexual-violence protocols.
- Tests
- ECG (sinus tachycardia; QRS widening suggests tricyclics), glucose, electrolytes, creatine kinase, renal function, temperature. Blood and urine samples for toxicology as early as possible, since scopolamine is eliminated within hours; routine screens usually do not detect it.
- Imaging
- Head CT if there is trauma or the picture is atypical; bladder ultrasound for retention.
Differential diagnosis
- Sympathomimetic toxicity (cocaine, amphetamines), which causes sweating
- Serotonin syndrome (clonus, diarrhoea, sweating)
- Neuroleptic malignant syndrome (rigidity, slow onset)
- Heat stroke
- Alcohol or sedative withdrawal, encephalitis, acute psychosis
Goal of treatment
Control agitation and temperature, protect the patient from harm, and support the body until the anticholinergic agent is cleared.
Treatment
- Acute
- ABC, calm low-stimulus environment, cooling for hyperthermia, intravenous fluids. Activated charcoal only if the airway is protected and ingestion was recent.
- Medical
- Benzodiazepines are first line for agitation and seizures; antipsychotics and other anticholinergic sedatives are avoided because they worsen the syndrome.
- Medical
- Physostigmine, a cholinesterase inhibitor that crosses into the brain, can reverse severe central delirium under monitoring in specialised settings; it is contraindicated when the ECG suggests tricyclic toxicity.
- Procedure
- Bladder catheterisation for urinary retention.
- Follow-up
- Nursing priorities: continuous cardiac monitoring, temperature, bladder volume, fall and self-harm prevention, minimal restraint; protect evidence and the victim's dignity in suspected crime and notify authorities as required.
Drugs for this condition
Complications
- Hyperthermia and rhabdomyolysis
- Seizures
- Arrhythmias
- Injuries during delirium; aspiration
- Acute angle-closure glaucoma in predisposed eyes
- Robbery, sexual violence and psychological trauma in criminal cases
Prognosis
Most patients recover within one to three days with supportive care. Severe cases can be fatal from hyperthermia, seizures or arrhythmias, and victims of scopolamine-facilitated crime may have lasting amnesia for the events.
Prevention
- Do not accept drinks, food, cigarettes or flyers from strangers; keep drinks in sight
- Avoid recreational use of borrachero or Datura
- Review and reduce anticholinergic burden in older adults
- Store medicines safely away from children
Test yourself
Think of the answer, then tap the question to see it.
Which skin finding best separates anticholinergic from sympathomimetic toxicity?
Dry skin: anticholinergic patients cannot sweat, whereas sympathomimetic patients are diaphoretic.
What is the drug of choice for agitation in anticholinergic delirium?
A benzodiazepine; antipsychotics with anticholinergic properties can worsen the syndrome.
When is physostigmine contraindicated?
When tricyclic antidepressant toxicity is suspected, such as QRS widening on the ECG, because it can provoke bradyarrhythmias and asystole.
Which plant source of scopolamine is common in the Colombian Andes?
Brugmansia («borrachero»), along with Datura species.
Why should toxicology samples be taken early in suspected burundanga cases?
Scopolamine is eliminated within hours, and routine screens rarely detect it, so early specific testing is needed for confirmation.
Related conditions
- Tricyclic antidepressant overdose
- Organophosphate and carbamate poisoning
- Heat stroke and heat exhaustion
- Acute urinary retention
- Acute angle-closure glaucoma
- Delirium
- Serotonin syndrome
- Neuroleptic malignant syndrome
- Cocaine and sympathomimetic toxicity
- Benzodiazepine overdose
- Status epilepticus
- Rhabdomyolysis
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Jimsonweed poisoning: MedlinePlus Medical Encyclopedia (MedlinePlus (U.S. National Library of Medicine), 2026); Guía para el manejo de emergencias toxicológicas (Ministerio de Salud y Protección Social (Colombia) / OPS, 2017).
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